Provider Demographics
NPI:1952792236
Name:RADIC, CHARLOTTE R (CNM, APRN)
Entity type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:R
Last Name:RADIC
Suffix:
Gender:F
Credentials:CNM, APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1430
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-9230
Mailing Address - Country:US
Mailing Address - Phone:219-763-8112
Mailing Address - Fax:219-764-3251
Practice Address - Street 1:800 ROSE ST
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536-2619
Practice Address - Country:US
Practice Address - Phone:859-323-5931
Practice Address - Fax:859-257-7520
Is Sole Proprietor?:No
Enumeration Date:2015-02-09
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN09000259A367A00000X
TN29843367A00000X
KY3018119367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201278230Medicaid