Healthcare Provider Details

I. General information

NPI: 1710816772
Provider Name (Legal Business Name): TIFFANY S RANDICH RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2026
Last Update Date: 05/15/2026
Certification Date: 05/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4525 3RD AVE SE
LACEY WA
98503-1010
US

IV. Provider business mailing address

4525 3RD AVE SE
LACEY WA
98503-1010
US

V. Phone/Fax

Practice location:
  • Phone: 360-754-3934
  • Fax:
Mailing address:
  • Phone: 360-580-4739
  • Fax: 360-412-8955

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WX0200X
TaxonomyOncology Registered Nurse
License NumberRN.RN.60802933
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: