Provider Demographics
NPI:1306198429
Name:MALLARI, RANDY (MSN, RN, CNL, CHC)
Entity Type:Individual
Prefix:MR
First Name:RANDY
Middle Name:
Last Name:MALLARI
Suffix:
Gender:M
Credentials:MSN, RN, CNL, CHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10250 N 124TH ST
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85259-5201
Mailing Address - Country:US
Mailing Address - Phone:602-908-8580
Mailing Address - Fax:480-590-6113
Practice Address - Street 1:10250 N 124TH ST
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85259-5201
Practice Address - Country:US
Practice Address - Phone:480-400-0850
Practice Address - Fax:602-860-6050
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-12
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN207973163W00000X, 163WE0003X
03D2046159247ZC0005X, 247ZC0005X, 247ZC0005X, 247ZC0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247ZC0005XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyClinical Laboratory Director, Non-physician
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WE0003XNursing Service ProvidersRegistered NurseEmergency
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ096781Medicaid
AZRN207973OtherARIZONA STATE BOARD OF NURSING
11547641OtherCOMMISSION ON NURSE CERTIFICATION
03D2253195OtherCLIA
AZRN207973OtherARIZONA STATE BOARD OF NURSING
AZBH6716OtherARIZONA DEPARTMENT OF HEALTH SERVICES