Healthcare Provider Details

I. General information

NPI: 1366468159
Provider Name (Legal Business Name): ANNETTE RANDLEMON CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 01/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 E 30TH ST BLDG B, SUITE 102
FARMINGTON NM
87401-8990
US

IV. Provider business mailing address

2017 SIERRA AVE
AZTEC NM
87410-1540
US

V. Phone/Fax

Practice location:
  • Phone: 505-324-1000
  • Fax: 505-324-1199
Mailing address:
  • Phone: 505-334-6896
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR25038
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: