1235418914 NPI number — LAURA JANE RANDALL AA

Table of content: LAURA JANE RANDALL AA (NPI 1235418914)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235418914 NPI number — LAURA JANE RANDALL AA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RANDALL
Provider First Name:
LAURA
Provider Middle Name:
JANE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
AA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PLUMMER
Provider Other First Name:
LAURA
Provider Other Middle Name:
JANE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
AA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1235418914
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/11/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 840853
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75284-0853
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-233-1999
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6606 LBJ FWY STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75240-6524
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-715-5000
Provider Business Practice Location Address Fax Number:
972-715-9976
Provider Enumeration Date:
08/11/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367H00000X , with the licence number: 1281 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)