Healthcare Provider Details

I. General information

NPI: 1952129686
Provider Name (Legal Business Name): ASHLEE LIANNE RADTKE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2024
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3060 FRONTIER WAY S
FARGO ND
58104-8909
US

IV. Provider business mailing address

308 10TH AVE E
WEST FARGO ND
58078-3004
US

V. Phone/Fax

Practice location:
  • Phone: 701-232-2340
  • Fax:
Mailing address:
  • Phone: 701-850-9950
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: