Provider Demographics
NPI:1134811011
Name:RADULOVIC, MANDA MARIA
Entity type:Individual
Prefix:
First Name:MANDA
Middle Name:MARIA
Last Name:RADULOVIC
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 1:9010 S PRIEST DR APT 3208
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85284-1194
Mailing Address - Country:US
Mailing Address - Phone:602-300-7949
Mailing Address - Fax:
Practice Address - Street 1:950 W ELLIOT RD
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85284-1144
Practice Address - Country:US
Practice Address - Phone:602-300-7949
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-22
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ86326199133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered