Provider Demographics
NPI:1477726834
Name:RANDOLPH, DARA ANN (RN)
Entity type:Individual
Prefix:
First Name:DARA
Middle Name:ANN
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:DARA
Other - Middle Name:
Other - Last Name:WALKER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:PO BOX 541
Mailing Address - Street 2:841 DOMINION ROAD
Mailing Address - City:GERRARDSTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:25420
Mailing Address - Country:US
Mailing Address - Phone:304-267-3595
Mailing Address - Fax:
Practice Address - Street 1:401 SOUTH QUEEN STREET
Practice Address - Street 2:BERKELEY COUNTY BOARD OF EDUCATION
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401
Practice Address - Country:US
Practice Address - Phone:304-267-3595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-08
Last Update Date:2008-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV62088163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810004180Medicaid