Healthcare Provider Details

I. General information

NPI: 1740617802
Provider Name (Legal Business Name): KATI LU RANDOLPH RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2013
Last Update Date: 10/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 OCEAN LAKE RD
RIVERTON WY
82501-8318
US

IV. Provider business mailing address

255 OCEAN LAKE RD
RIVERTON WY
82501-0000
US

V. Phone/Fax

Practice location:
  • Phone: 307-851-6387
  • Fax: 307-332-0131
Mailing address:
  • Phone: 307-851-6387
  • Fax: 307-332-0131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number32141
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: