Provider Demographics
NPI:1245534726
Name:RADOSEVICH, MARY ELLEN (FNP-C)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN
Last Name:RADOSEVICH
Suffix:
Gender:
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4375 E IRMA LN
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85050-4312
Mailing Address - Country:US
Mailing Address - Phone:480-890-5800
Mailing Address - Fax:
Practice Address - Street 1:4375 E IRMA LN
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85050-4312
Practice Address - Country:US
Practice Address - Phone:480-890-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-27
Last Update Date:2025-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP3727363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner