Provider Demographics
NPI:1295465011
Name:RADAVICH, CINDY JEAN (APRN)
Entity Type:Individual
Prefix:
First Name:CINDY
Middle Name:JEAN
Last Name:RADAVICH
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5920 N GOVT WAY STE 2
Mailing Address - Street 2:
Mailing Address - City:DALTON GARDENS
Mailing Address - State:ID
Mailing Address - Zip Code:83815-9200
Mailing Address - Country:US
Mailing Address - Phone:208-696-4462
Mailing Address - Fax:
Practice Address - Street 1:5920 N GOVT WAY STE 2
Practice Address - Street 2:
Practice Address - City:DALTON GARDENS
Practice Address - State:ID
Practice Address - Zip Code:83815-9200
Practice Address - Country:US
Practice Address - Phone:208-696-4462
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-14
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDAPRN-CNP54724363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care