Provider Demographics
NPI:1184465148
Name:RANDALL, OLIVIA (NP-PMHNP)
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:
Last Name:RANDALL
Suffix:
Gender:F
Credentials:NP-PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1525 N RENAISSANCE BLVD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107-6827
Mailing Address - Country:US
Mailing Address - Phone:276-734-2799
Mailing Address - Fax:
Practice Address - Street 1:1525 N RENAISSANCE BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-6827
Practice Address - Country:US
Practice Address - Phone:505-243-3387
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-04
Last Update Date:2025-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM77359363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health