Healthcare Provider Details

I. General information

NPI: 1215536313
Provider Name (Legal Business Name): RANDI KELLIE WADEMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2020
Last Update Date: 04/09/2025
Certification Date: 04/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11512 B AVE
AUBURN CA
95603-2605
US

IV. Provider business mailing address

500 CROWN POINT CIR
GRASS VALLEY CA
95945-9561
US

V. Phone/Fax

Practice location:
  • Phone: 530-889-7240
  • Fax: 530-889-7293
Mailing address:
  • Phone: 530-265-1437
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: