Provider Demographics
NPI:1912673674
Name:GLADNEY, LADONNA JENIQUE (NDTR, CPT)
Entity Type:Individual
Prefix:
First Name:LADONNA
Middle Name:JENIQUE
Last Name:GLADNEY
Suffix:
Gender:F
Credentials:NDTR, CPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3332 N 78TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53222-3920
Mailing Address - Country:US
Mailing Address - Phone:866-252-2989
Mailing Address - Fax:
Practice Address - Street 1:608 E CLARKE ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212-2925
Practice Address - Country:US
Practice Address - Phone:866-252-2989
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-20
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI136A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes136A00000XDietary & Nutritional Service ProvidersDietetic Technician, Registered