Provider Demographics
NPI:1578511739
Name:RADOVICH, CAROL LYNN (NP)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:LYNN
Last Name:RADOVICH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W197N17054 STONEWALL DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WI
Mailing Address - Zip Code:53037
Mailing Address - Country:US
Mailing Address - Phone:847-922-9203
Mailing Address - Fax:
Practice Address - Street 1:W197N17054 STONEWALL DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WI
Practice Address - Zip Code:53037
Practice Address - Country:US
Practice Address - Phone:847-922-9203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2019-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209004029363LA2200X
WI8119-33363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00275524OtherMEDICARE RAILROAD
IL962341OtherMEDICARE
ILP00275524OtherMEDICARE RAILROAD