Provider Demographics
NPI:1104327535
Name:CANNADAY, MOENEEK
Entity type:Individual
Prefix:
First Name:MOENEEK
Middle Name:
Last Name:CANNADAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:804 CLINTON ST
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186-4797
Mailing Address - Country:US
Mailing Address - Phone:262-617-0195
Mailing Address - Fax:
Practice Address - Street 1:804 CLINTON ST
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186-4797
Practice Address - Country:US
Practice Address - Phone:262-617-0195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-21
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100034083Medicaid