Provider Demographics
NPI:1245719194
Name:RADIONOFF, TAMMY (NP)
Entity type:Individual
Prefix:
First Name:TAMMY
Middle Name:
Last Name:RADIONOFF
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 HOBART ST
Mailing Address - Street 2:
Mailing Address - City:CADILLAC
Mailing Address - State:MI
Mailing Address - Zip Code:49601-2331
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:400 HOBART ST
Practice Address - Street 2:
Practice Address - City:CADILLAC
Practice Address - State:MI
Practice Address - Zip Code:49601-2331
Practice Address - Country:US
Practice Address - Phone:231-876-6421
Practice Address - Fax:231-876-6430
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-11
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704280351363L00000X
MI470280351363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner