Provider Demographics
NPI:1891978763
Name:RANDALL, JUDITH MYRICK (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:JUDITH
Middle Name:MYRICK
Last Name:RANDALL
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1890 WAITE ST
Mailing Address - Street 2:STE 1
Mailing Address - City:NORTH BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97459-1229
Mailing Address - Country:US
Mailing Address - Phone:541-756-6232
Mailing Address - Fax:541-756-6234
Practice Address - Street 1:1890 WAITE ST
Practice Address - Street 2:STE 1
Practice Address - City:NORTH BEND
Practice Address - State:OR
Practice Address - Zip Code:97459-1229
Practice Address - Country:US
Practice Address - Phone:541-756-6232
Practice Address - Fax:541-756-6234
Is Sole Proprietor?:No
Enumeration Date:2007-12-13
Last Update Date:2012-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30007876363LF0000X
OR201250024363LF0000X
OR201250025NP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
1619915113OtherWATERFALL CLINIC, INC. GROUP NPI
OR213342Medicaid
R120353OtherGROUP PTAN NUMBER
1619915113OtherWATERFALL CLINIC, INC. GROUP NPI
381902Medicare Oscar/Certification