Basic Information
| Provider Information | |||||||||
| NPI: | 1346714128 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RADCLIFF | ||||||||
| FirstName: | KATIE | ||||||||
| MiddleName: | A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6716 NW 11TH PL STE 200 | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326054201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523319729 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6716 NW 11TH PL STE 200 | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326054201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523319729 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2019 | ||||||||
| LastUpdateDate: | 03/10/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA9111953 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1018569-00 | 05 | FL | MEDICAID | RE89Z | 01 | FL | BCBS | OTHER | KT701 | 01 | FL | MEDICARE | OTHER | KT707 | 01 | FL | MEDICARE | OTHER |