Provider Demographics
NPI:1043330798
Name:RADAKOVICH, KATHERINE M (FNP-BC)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:M
Last Name:RADAKOVICH
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:803 W ARLINGTON ST
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:MI
Mailing Address - Zip Code:49013-1108
Mailing Address - Country:US
Mailing Address - Phone:269-427-6810
Mailing Address - Fax:269-427-6811
Practice Address - Street 1:803 W ARLINGTON ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:MI
Practice Address - Zip Code:49013-1108
Practice Address - Country:US
Practice Address - Phone:269-427-6810
Practice Address - Fax:269-427-6811
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2017-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
857942133V00000X
AK1139363LF0000X
FLARNP9321730363LF0000X
MI4704285987363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003650500Medicaid
FLFO774YMedicare PIN