Provider Demographics
NPI:1609424662
Name:RADZINSKI, JEANINE MODESTA (RN)
Entity Type:Individual
Prefix:
First Name:JEANINE
Middle Name:MODESTA
Last Name:RADZINSKI
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17W604 HAWTHORNE AVE
Mailing Address - Street 2:
Mailing Address - City:WOOD DALE
Mailing Address - State:IL
Mailing Address - Zip Code:60191-1456
Mailing Address - Country:US
Mailing Address - Phone:331-642-2824
Mailing Address - Fax:
Practice Address - Street 1:1522 BEACH AVE
Practice Address - Street 2:
Practice Address - City:LA GRANGE PARK
Practice Address - State:IL
Practice Address - Zip Code:60526-1247
Practice Address - Country:US
Practice Address - Phone:708-715-4015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-03
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.289998163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL041.289998OtherRN LICENSE