Provider Demographics
NPI:1366468159
Name:RANDLEMON, ANNETTE (CNP)
Entity Type:Individual
Prefix:
First Name:ANNETTE
Middle Name:
Last Name:RANDLEMON
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2017 SIERRA AVE
Mailing Address - Street 2:
Mailing Address - City:AZTEC
Mailing Address - State:NM
Mailing Address - Zip Code:87410-1540
Mailing Address - Country:US
Mailing Address - Phone:505-334-6896
Mailing Address - Fax:
Practice Address - Street 1:2300 E 30TH ST
Practice Address - Street 2:BLDG B, SUITE 102
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-8990
Practice Address - Country:US
Practice Address - Phone:505-324-1000
Practice Address - Fax:505-324-1199
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR25038363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM850462631OtherSTATE ID
NM850462631OtherCIGNA
NM10002777OtherLOVELACE SALUD
NM201016092OtherPRESBYTERIAN
32D0943693OtherCLIA
NMS3309Medicaid
NM400521029OtherEMC
NMNM006F13OtherBLUE CROSS