Healthcare Provider Details

I. General information

NPI: 1184465148
Provider Name (Legal Business Name): OLIVIA RANDALL NP-PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2024
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4550 EUBANK BLVD NE STE 107
ALBUQUERQUE NM
87111-2565
US

IV. Provider business mailing address

1525 N RENAISSANCE BLVD NE
ALBUQUERQUE NM
87107-6827
US

V. Phone/Fax

Practice location:
  • Phone: 505-503-8806
  • Fax: 888-503-8511
Mailing address:
  • Phone: 276-734-2799
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number77359
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: