Provider Demographics
NPI:1922352350
Name:RODDY, RANDA DEANNE (RN)
Entity Type:Individual
Prefix:MS
First Name:RANDA
Middle Name:DEANNE
Last Name:RODDY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MS
Other - First Name:RANDA
Other - Middle Name:DEANNE
Other - Last Name:YOUNGBLOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:PO BOX 155
Mailing Address - Street 2:
Mailing Address - City:CHRISTOPHER
Mailing Address - State:IL
Mailing Address - Zip Code:62822-0155
Mailing Address - Country:US
Mailing Address - Phone:618-724-2436
Mailing Address - Fax:
Practice Address - Street 1:14410 ROUTE 37
Practice Address - Street 2:
Practice Address - City:JOHNSTON CITY
Practice Address - State:IL
Practice Address - Zip Code:62951-3166
Practice Address - Country:US
Practice Address - Phone:618-983-6911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-07
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041337855163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse