Provider Demographics
NPI:1659345239
Name:RADICE, JENNIFER RACHELLE (MSN, FNP-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:RACHELLE
Last Name:RADICE
Suffix:
Gender:F
Credentials:MSN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3292 DIXIE RD SW
Mailing Address - Street 2:P.O. BOX 7
Mailing Address - City:CORYDON
Mailing Address - State:IN
Mailing Address - Zip Code:47112-0007
Mailing Address - Country:US
Mailing Address - Phone:812-764-5322
Mailing Address - Fax:
Practice Address - Street 1:1007 LINCOLNWAY
Practice Address - Street 2:
Practice Address - City:LA PORTE
Practice Address - State:IN
Practice Address - Zip Code:46350-3290
Practice Address - Country:US
Practice Address - Phone:219-326-1234
Practice Address - Fax:219-326-2699
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN260019363L00000X
IN71001559A363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
INM400050240Medicare UPIN
KYK006540Medicare UPIN