Provider Demographics
NPI:1396943627
Name:SOBEL-RADKE, SALLY JO (RN, NNP)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:JO
Last Name:SOBEL-RADKE
Suffix:
Gender:F
Credentials:RN, NNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 AMERICAN AVE 3RD FL NICU
Mailing Address - Street 2:PROHEALTH CARE MEDICAL ASSOCIATES INC.
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-5031
Mailing Address - Country:US
Mailing Address - Phone:262-928-7276
Mailing Address - Fax:
Practice Address - Street 1:725 AMERICAN AVE 3RD FL NICU
Practice Address - Street 2:PROHEALTH CARE MEDICAL ASSOCIATES INC.
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-5031
Practice Address - Country:US
Practice Address - Phone:262-928-7276
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-09
Last Update Date:2013-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN180310-9163WN0002X
WI96429-030163WN0002X
WI1022363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
No163WN0002XNursing Service ProvidersRegistered NurseNeonatal Intensive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
68375Medicare PIN