Provider Demographics
NPI:1982247540
Name:RADFORD, JOHNA ANN (FNP-BC)
Entity Type:Individual
Prefix:
First Name:JOHNA
Middle Name:ANN
Last Name:RADFORD
Suffix:
Gender:F
Credentials:FNP-BC
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 5909
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97228-5909
Mailing Address - Country:US
Mailing Address - Phone:574-273-6767
Mailing Address - Fax:
Practice Address - Street 1:710 PARK PL
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-3519
Practice Address - Country:US
Practice Address - Phone:574-273-6767
Practice Address - Fax:574-968-7160
Is Sole Proprietor?:No
Enumeration Date:2019-10-25
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28147796A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily