1871602664 NPI number — MS. CONNIE MALLO RANDAZZO CNS

Table of content: MS. CONNIE MALLO RANDAZZO CNS (NPI 1871602664)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871602664 NPI number — MS. CONNIE MALLO RANDAZZO CNS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RANDAZZO
Provider First Name:
CONNIE
Provider Middle Name:
MALLO
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
CNS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MALLO
Provider Other First Name:
CONNIE
Provider Other Middle Name:
F
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1871602664
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/26/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

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

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2620 E PROSPECT RD
Provider Second Line Business Practice Location Address:
SUITE 190
Provider Business Practice Location Address City Name:
FORT COLLINS
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80525-9098
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-221-1106
Provider Business Practice Location Address Fax Number:
970-232-1050
Provider Enumeration Date:
08/29/2006

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: 364SP0808X , with the licence number:  81170 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 87954770 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".