Provider Demographics
NPI:1215178801
Name:RANDOLPH, DEEANNE CONEA (LMP)
Entity Type:Individual
Prefix:
First Name:DEEANNE
Middle Name:CONEA
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:706 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98402-3712
Mailing Address - Country:US
Mailing Address - Phone:253-473-7830
Mailing Address - Fax:
Practice Address - Street 1:706 MARKET STREET
Practice Address - Street 2:SERENITY SPA
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402
Practice Address - Country:US
Practice Address - Phone:253-473-7830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-12
Last Update Date:2009-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00016331174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist