Provider Demographics
NPI:1346511441
Name:RANDALL, NITA LOUISE (RN)
Entity Type:Individual
Prefix:MRS
First Name:NITA
Middle Name:LOUISE
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 1:6109 W 3700 N
Mailing Address - Street 2:
Mailing Address - City:IVINS
Mailing Address - State:UT
Mailing Address - Zip Code:84738-6663
Mailing Address - Country:US
Mailing Address - Phone:435-688-8198
Mailing Address - Fax:435-688-8199
Practice Address - Street 1:6109 W 3700 N
Practice Address - Street 2:
Practice Address - City:IVINS
Practice Address - State:UT
Practice Address - Zip Code:84738-6663
Practice Address - Country:US
Practice Address - Phone:435-688-8198
Practice Address - Fax:435-688-8199
Is Sole Proprietor?:No
Enumeration Date:2012-01-20
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT73103553102163W00000X
MI4704222572163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse