Provider Demographics
NPI:1598120479
Name:RADLOFF, MARITA
Entity Type:Individual
Prefix:
First Name:MARITA
Middle Name:
Last Name:RADLOFF
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARITA
Other - Middle Name:
Other - Last Name:O'GRADY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDN, LD
Mailing Address - Street 1:655 7TH ST
Mailing Address - Street 2:BLDG 700/700-A
Mailing Address - City:ROBINS AFB
Mailing Address - State:GA
Mailing Address - Zip Code:31098-2227
Mailing Address - Country:US
Mailing Address - Phone:478-222-6904
Mailing Address - Fax:
Practice Address - Street 1:655 7TH ST
Practice Address - Street 2:BLDG 700/700-A
Practice Address - City:ROBINS AFB
Practice Address - State:GA
Practice Address - Zip Code:31098-2227
Practice Address - Country:US
Practice Address - Phone:478-222-6904
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-21
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA86055256133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered