Healthcare Provider Details

I. General information

NPI: 1295328029
Provider Name (Legal Business Name): EMMA JANE RADKE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2021
Last Update Date: 10/10/2023
Certification Date: 10/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1545 ORCHARD VILLAS AVE STE 100
APEX NC
27502-4339
US

IV. Provider business mailing address

9632 RED PINE DR
PLYMOUTH MI
48170-3269
US

V. Phone/Fax

Practice location:
  • Phone: 919-576-8383
  • Fax:
Mailing address:
  • Phone: 734-680-5717
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2000041172
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: