Provider Demographics
NPI:1689262420
Name:RANDOLPH, HEATHER LYNN (LM, CPM)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:LYNN
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:LM, CPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1724 CAPROCK RDG
Mailing Address - Street 2:
Mailing Address - City:HELOTES
Mailing Address - State:TX
Mailing Address - Zip Code:78023-3046
Mailing Address - Country:US
Mailing Address - Phone:405-714-2901
Mailing Address - Fax:
Practice Address - Street 1:1724 CAPROCK RDG
Practice Address - Street 2:
Practice Address - City:HELOTES
Practice Address - State:TX
Practice Address - Zip Code:78023-3046
Practice Address - Country:US
Practice Address - Phone:405-714-2901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-07
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX99309176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife