Provider Demographics
NPI:1346714128
Name:RADCLIFF, KATIE A
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:A
Last Name:RADCLIFF
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 1:6716 NW 11TH PL STE 200
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32605-4201
Mailing Address - Country:US
Mailing Address - Phone:352-331-9729
Mailing Address - Fax:
Practice Address - Street 1:6716 NW 11TH PL STE 200
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32605-4201
Practice Address - Country:US
Practice Address - Phone:352-331-9729
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-15
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
FLPA9111953363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1018569-00Medicaid
FLRE89ZOtherBCBS
FLKT701OtherMEDICARE
FLKT707OtherMEDICARE