Provider Demographics
NPI:1982734711
Name:RANDALL, KATHI SALLEY (RNC, MSN, CNS, NNP)
Entity Type:Individual
Prefix:
First Name:KATHI
Middle Name:SALLEY
Last Name:RANDALL
Suffix:
Gender:F
Credentials:RNC, MSN, CNS, NNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28141 BELLETERRE AVE
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92555-6223
Mailing Address - Country:US
Mailing Address - Phone:909-558-4403
Mailing Address - Fax:
Practice Address - Street 1:28141 BELLETERRE AVE
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92555-6223
Practice Address - Country:US
Practice Address - Phone:909-558-4403
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA504615363LN0005X
CA1392364SN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care
Not Answered364SN0000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistNeonatal