MEDICARE: MS. CONNIE MALLO RANDAZZO CNS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	364SP0808X	Psychiatric/Mental Health Clinical Nurse Specialist	81170	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1871602664
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CONNIE MALLO RANDAZZO CNS

Provider Business Mailing Address
First Line	:	2620 E PROSPECT RD
Second Line	:	SUITE 190
City	:	FORT COLLINS
State	:	CO
Zip	:	80525-9098
Country	:	US
Telephone Number	:	970-221-1106
Fax Number	:	970-232-1050

Provider Business Practice Location Address
First Line	:	2620 E PROSPECT RD
Second Line	:	SUITE 190
City	:	FORT COLLINS
State	:	CO
Zip	:	80525-9098
Country	:	US
Telephone Number	:	970-221-1106
Fax Number	:	970-232-1050

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/29/2006
Last Update Date	:	05/26/2016

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