Provider Demographics
NPI:1659098036
Name:RADZIK, MALLORY M (FNP)
Entity Type:Individual
Prefix:DR
First Name:MALLORY
Middle Name:M
Last Name:RADZIK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2009 BRYS DR
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48236-1039
Mailing Address - Country:US
Mailing Address - Phone:586-864-2887
Mailing Address - Fax:
Practice Address - Street 1:2009 BRYS DR
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE WOODS
Practice Address - State:MI
Practice Address - Zip Code:48236-1039
Practice Address - Country:US
Practice Address - Phone:586-864-2887
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-26
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704309438363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily