Healthcare Provider Details

I. General information

NPI: 1700602364
Provider Name (Legal Business Name): RADIANT PRIME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2024
Last Update Date: 04/24/2025
Certification Date: 04/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7075 WADES MILL RD
MOUNT STERLING KY
40353-8293
US

IV. Provider business mailing address

4948 REFLECTING POND CIR
WIMAUMA FL
33598-4064
US

V. Phone/Fax

Practice location:
  • Phone: 813-384-8050
  • Fax: 813-336-8804
Mailing address:
  • Phone: 813-384-8050
  • Fax: 813-336-8804

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. JESSICA NICOLE MCGLONE
Title or Position: OWNER & CEO
Credential: APRN
Phone: 813-384-8050