Healthcare Provider Details

I. General information

NPI: 1346511441
Provider Name (Legal Business Name): NITA LOUISE RANDALL R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2012
Last Update Date: 01/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6109 W 3700 N
IVINS UT
84738-6663
US

IV. Provider business mailing address

6109 W 3700 N
IVINS UT
84738-6663
US

V. Phone/Fax

Practice location:
  • Phone: 435-688-8198
  • Fax: 435-688-8199
Mailing address:
  • Phone: 435-688-8198
  • Fax: 435-688-8199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number73103553102
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704222572
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: