Provider Demographics
NPI:1740617802
Name:RANDOLPH, KATI LU (RN)
Entity Type:Individual
Prefix:
First Name:KATI
Middle Name:LU
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 OCEAN LAKE RD
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:WY
Mailing Address - Zip Code:82501-0000
Mailing Address - Country:US
Mailing Address - Phone:307-851-6387
Mailing Address - Fax:307-332-0131
Practice Address - Street 1:255 OCEAN LAKE RD
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501-8318
Practice Address - Country:US
Practice Address - Phone:307-851-6387
Practice Address - Fax:307-332-0131
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-03
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY32141163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY32141OtherLICENSE