Provider Demographics
NPI:1164860771
Name:RANDALL, MARY PAT S (RN)
Entity Type:Individual
Prefix:
First Name:MARY PAT
Middle Name:S
Last Name:RANDALL
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11461 FREDMAR DR
Mailing Address - Street 2:
Mailing Address - City:INTERLOCHEN
Mailing Address - State:MI
Mailing Address - Zip Code:49643-9523
Mailing Address - Country:US
Mailing Address - Phone:231-590-8624
Mailing Address - Fax:
Practice Address - Street 1:11461 FREDMAR DR
Practice Address - Street 2:
Practice Address - City:INTERLOCHEN
Practice Address - State:MI
Practice Address - Zip Code:49643-9523
Practice Address - Country:US
Practice Address - Phone:231-590-8624
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-06
Last Update Date:2013-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704107861163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management