Provider Demographics
NPI:1770856908
Name:RADTKE, ELIZABETH KAY
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:KAY
Last Name:RADTKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42100 585TH ST
Mailing Address - Street 2:
Mailing Address - City:MAZEPPA
Mailing Address - State:MN
Mailing Address - Zip Code:55956-7542
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:42100 585TH ST
Practice Address - Street 2:
Practice Address - City:MAZEPPA
Practice Address - State:MN
Practice Address - Zip Code:55956-7542
Practice Address - Country:US
Practice Address - Phone:651-380-3548
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-19
Last Update Date:2012-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR193989-5163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse