Provider Demographics
NPI:1689075988
Name:RANDALL, DIANNE (IBCLC)
Entity Type:Individual
Prefix:
First Name:DIANNE
Middle Name:
Last Name:RANDALL
Suffix:
Gender:F
Credentials:IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4472 HERITAGE GLEN LN
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-2418
Mailing Address - Country:US
Mailing Address - Phone:858-481-2450
Mailing Address - Fax:
Practice Address - Street 1:4472 HERITAGE GLEN LN
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130-2418
Practice Address - Country:US
Practice Address - Phone:858-481-2450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-06
Last Update Date:2014-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11294505174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN