Provider Demographics
NPI:1376881607
Name:RADVANSKY, MALLORY (CFNP)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:RADVANSKY
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 645409
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15264-5252
Mailing Address - Country:US
Mailing Address - Phone:330-386-6442
Mailing Address - Fax:330-386-3660
Practice Address - Street 1:425 W 5TH ST
Practice Address - Street 2:
Practice Address - City:EAST LIVERPOOL
Practice Address - State:OH
Practice Address - Zip Code:43920-2405
Practice Address - Country:US
Practice Address - Phone:330-386-5279
Practice Address - Fax:330-386-5866
Is Sole Proprietor?:No
Enumeration Date:2013-01-22
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP015019363LF0000X
OHAPRN.CNP.14103363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP01326293OtherRR MEDICARE
OH0079443Medicaid
OHH168420Medicare UPIN
OH0079443Medicaid