Healthcare Provider Details

I. General information

NPI: 1891301198
Provider Name (Legal Business Name): MICHELLE LEA RADDATZ RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MICHELLE LEA UPCHURCH RN

II. Dates (important events)

Enumeration Date: 09/22/2020
Last Update Date: 09/22/2020
Certification Date: 09/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

US ARMY MEDICAL ACTIVITY-BAVARIA UNIT 28038 ATTN: MCEU-BAV-CRE
APO AE
09112
US

IV. Provider business mailing address

CMR 480 BOX 840
APO AE
09128-0009
US

V. Phone/Fax

Practice location:
  • Phone: 496-371-9464
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number136402
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: