1245562800 NPI number — LAKEIDRIA RANDALL CRNA

Table of content: LAKEIDRIA RANDALL CRNA (NPI 1245562800)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245562800 NPI number — LAKEIDRIA RANDALL CRNA

Organization/Personal Information

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

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RANDALL
Provider Other First Name:
LAKEIDRIA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
CRNA
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1245562800
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/22/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7777 HENNESSY BLVD
Provider Second Line Business Mailing Address:
STE. 301
Provider Business Mailing Address City Name:
BATON ROUGE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70808-4300
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-592-2957
Provider Business Mailing Address Fax Number:
225-214-6437

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7777 HENNESSY BLVD
Provider Second Line Business Practice Location Address:
STE. 301
Provider Business Practice Location Address City Name:
BATON ROUGE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70808-4300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-592-2957
Provider Business Practice Location Address Fax Number:
225-214-6437
Provider Enumeration Date:
02/08/2010

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: 163WA2000X , with the licence number:  112518 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: AP07633 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2353403 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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