Healthcare Provider Details

I. General information

NPI: 1386615417
Provider Name (Legal Business Name): JUEL N RADTKE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1060 GAFFNEY RD COMMANDER, USA-MEDDAC-AK, ATTN: MCUC-MMD-QM
FT WAINWRIGHT AK
99703-5001
US

IV. Provider business mailing address

1060 GAFFNEY RD COMMANDER, USA-MEDDAC-AK, ATTN: MCUC-MMD-QM
FT WAINWRIGHT AK
99703-5001
US

V. Phone/Fax

Practice location:
  • Phone: 907-353-5158
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0102X
TaxonomyMaternal Newborn Registered Nurse
License Number85851-030
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: