Healthcare Provider Details

I. General information

NPI: 1245719194
Provider Name (Legal Business Name): TAMMY RADIONOFF NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2018
Last Update Date: 01/05/2023
Certification Date: 01/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 HOBART ST
CADILLAC MI
49601-2331
US

IV. Provider business mailing address

400 HOBART ST
CADILLAC MI
49601-2331
US

V. Phone/Fax

Practice location:
  • Phone: 231-876-6421
  • Fax: 231-876-6430
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704280351
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number470280351
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: