Provider Demographics
NPI:1669653978
Name:PROCKNOW, RANDALL NORMAN (RN)
Entity Type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:NORMAN
Last Name:PROCKNOW
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4352 HARBOR VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:OMRO
Mailing Address - State:WI
Mailing Address - Zip Code:54963-9498
Mailing Address - Country:US
Mailing Address - Phone:920-685-0898
Mailing Address - Fax:920-685-2204
Practice Address - Street 1:4352 HARBOR VILLAGE DR
Practice Address - Street 2:
Practice Address - City:OMRO
Practice Address - State:WI
Practice Address - Zip Code:54963-9498
Practice Address - Country:US
Practice Address - Phone:920-685-0898
Practice Address - Fax:920-685-2204
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-15
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI58624163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38249600Medicaid