MEDICARE: MADELYNN WHITESIDES RANDALL FNP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	11565765-4405	UT

General Provider Information

NPI Number	:	1700660065
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MADELYNN WHITESIDES RANDALL FNP-C

Provider Business Mailing Address
First Line	:	1736 S HAVEN PKWY
Second Line	:
City	:	WEST HAVEN
State	:	UT
Zip	:	84401-7134
Country	:	US
Telephone Number	:	801-540-8739
Fax Number	:

Provider Business Practice Location Address
First Line	:	1756 W ANTELOPE DR
Second Line	:
City	:	LAYTON
State	:	UT
Zip	:	84041-1143
Country	:	US
Telephone Number	:	801-773-4865
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/18/2023
Last Update Date	:	08/18/2023

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