Basic Information
| Provider Information | |||||||||
| NPI: | 1912943663 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RADTKE | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | F.N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1159 HOLTON WHITEHALL RD | ||||||||
| Address2: | |||||||||
| City: | WHITEHALL | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494619143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2318949167 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 218 N MICHIGAN AVE | ||||||||
| Address2: | |||||||||
| City: | SHELBY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494551028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2318612187 | ||||||||
| FaxNumber: | 2318946248 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 4704153426 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.