Provider Demographics
NPI:1962985747
Name:RADMALL, JESSICA COLEMAN (CNM)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:COLEMAN
Last Name:RADMALL
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:RADMALL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CNM
Mailing Address - Street 1:529 OAKHOLLOW CT
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-3360
Mailing Address - Country:US
Mailing Address - Phone:180-183-4246
Mailing Address - Fax:
Practice Address - Street 1:2152 S VINEYARD STE 138
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-6882
Practice Address - Country:US
Practice Address - Phone:480-539-6646
Practice Address - Fax:480-539-6696
Is Sole Proprietor?:No
Enumeration Date:2018-09-07
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP11704367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAP11704OtherARIZONA BOARD OF NURSING- CNM LICENSE