Provider Demographics
NPI:1700660065
Name:RANDALL, MADELYNN WHITESIDES (FNP-C)
Entity Type:Individual
Prefix:
First Name:MADELYNN
Middle Name:WHITESIDES
Last Name:RANDALL
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1736 S HAVEN PKWY
Mailing Address - Street 2:
Mailing Address - City:WEST HAVEN
Mailing Address - State:UT
Mailing Address - Zip Code:84401-7134
Mailing Address - Country:US
Mailing Address - Phone:801-540-8739
Mailing Address - Fax:
Practice Address - Street 1:1756 W ANTELOPE DR
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-1143
Practice Address - Country:US
Practice Address - Phone:801-773-4865
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-18
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11565765-4405363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner