Provider Demographics
NPI:1366832974
Name:RANDELL, LAURA (LPN)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:RANDELL
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N5820 LAKEVIEW CT E
Mailing Address - Street 2:
Mailing Address - City:ONALASKA
Mailing Address - State:WI
Mailing Address - Zip Code:54650-9637
Mailing Address - Country:US
Mailing Address - Phone:608-519-0775
Mailing Address - Fax:
Practice Address - Street 1:N5820 LAKEVIEW CT E
Practice Address - Street 2:
Practice Address - City:ONALASKA
Practice Address - State:WI
Practice Address - Zip Code:54650-9637
Practice Address - Country:US
Practice Address - Phone:608-519-0775
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-03
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI305839164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse