Provider Demographics
NPI:1285392274
Name:RADOSTA, STACIE
Entity type:Individual
Prefix:
First Name:STACIE
Middle Name:
Last Name:RADOSTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:822 S CLEARVIEW PKWY
Mailing Address - Street 2:
Mailing Address - City:HARAHAN
Mailing Address - State:LA
Mailing Address - Zip Code:70123-3401
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:JEFFERSON PARISH SCHOOL
Practice Address - Street 2:822 S. CLEARVIEW PARKWAY
Practice Address - City:HARHAN
Practice Address - State:LA
Practice Address - Zip Code:70123
Practice Address - Country:US
Practice Address - Phone:504-457-5129
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-07
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA163WS0200X163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1701033Medicaid