Provider Demographics
NPI:1003390105
Name:RANDAHL, SAMANTHA LEE (NMD)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:LEE
Last Name:RANDAHL
Suffix:
Gender:F
Credentials:NMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10153 E HAMPTON AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85209-3326
Mailing Address - Country:US
Mailing Address - Phone:480-535-5688
Mailing Address - Fax:
Practice Address - Street 1:10153 E HAMPTON AVE STE 104
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85209-3326
Practice Address - Country:US
Practice Address - Phone:480-535-5688
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-24
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ18-1733175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath