Provider Demographics
NPI:1831259514
Name:RADLIFF, MARY DIANE (ANP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:DIANE
Last Name:RADLIFF
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 ALBANY AVE
Mailing Address - Street 2:
Mailing Address - City:COBLESKILL
Mailing Address - State:NY
Mailing Address - Zip Code:12043
Mailing Address - Country:US
Mailing Address - Phone:518-255-5225
Mailing Address - Fax:518-255-5819
Practice Address - Street 1:130 ALBANY AVE
Practice Address - Street 2:
Practice Address - City:COBLESKILL
Practice Address - State:NY
Practice Address - Zip Code:12043
Practice Address - Country:US
Practice Address - Phone:518-255-5225
Practice Address - Fax:518-255-5819
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY30-301409363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health