Provider Demographics
NPI:1326762063
Name:WHITE, RANDI DAWN
Entity Type:Individual
Prefix:
First Name:RANDI
Middle Name:DAWN
Last Name:WHITE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 N HUDSON ST STE B
Mailing Address - Street 2:
Mailing Address - City:SILVER CITY
Mailing Address - State:NM
Mailing Address - Zip Code:88061-5436
Mailing Address - Country:US
Mailing Address - Phone:575-956-6478
Mailing Address - Fax:
Practice Address - Street 1:607 N HUDSON ST
Practice Address - Street 2:
Practice Address - City:SILVER CITY
Practice Address - State:NM
Practice Address - Zip Code:88061-5436
Practice Address - Country:US
Practice Address - Phone:575-956-6478
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-27
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM7780225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist