Healthcare Provider Details

I. General information

NPI: 1477726834
Provider Name (Legal Business Name): DARA ANN RANDOLPH RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: DARA WALKER RN

II. Dates (important events)

Enumeration Date: 04/08/2008
Last Update Date: 12/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 SOUTH QUEEN STREET BERKELEY COUNTY BOARD OF EDUCATION
MARTINSBURG WV
25401
US

IV. Provider business mailing address

PO BOX 541 841 DOMINION ROAD
GERRARDSTOWN WV
25420
US

V. Phone/Fax

Practice location:
  • Phone: 304-267-3595
  • Fax:
Mailing address:
  • Phone: 304-267-3595
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number62088
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: