Healthcare Provider Details

I. General information

NPI: 1649997057
Provider Name (Legal Business Name): ANGELICA JERI RADEVSKI BSN, LCCE, SPCPE, RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2022
Last Update Date: 10/26/2022
Certification Date: 10/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

816 NATIONAL RD
WHEELING WV
26003-6439
US

IV. Provider business mailing address

18 MASER AVE
WHEELING WV
26003
US

V. Phone/Fax

Practice location:
  • Phone: 304-639-8799
  • Fax:
Mailing address:
  • Phone: 304-639-8799
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WW0101X
TaxonomyAmbulatory Women's Health Care Registered Nurse
License Number100940
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: