Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LF0000X | Nurse Practitioner - Family Medicine | 677695 | TX |
NPI | 1003057829 |
---|---|
Provider Name | Jessica A Radley |
First Address | Columbus, TX 78934-3009 |
Second Address | Columbus, TX 78934-3009 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/03/2009 |
Last Update Date | 04/04/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
677695 | LICENSE NUMBER (01) | TX |