Basic Information
| Provider Information | |||||||||
| NPI: | 1942776885 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RADKE | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | TERESE | ||||||||
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| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10126 43RD CT NE | ||||||||
| Address2: | |||||||||
| City: | SAINT MICHAEL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553763015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7634977154 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4050 COON RAPIDS BLVD NW | ||||||||
| Address2: | |||||||||
| City: | COON RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554332522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6516359173 | ||||||||
| FaxNumber: | 6516282999 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2018 | ||||||||
| LastUpdateDate: | 03/11/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 6252 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.