1023100575 NPI number — RANDINE D NADEAU PMHNP, FNP

Table of content: RANDINE D NADEAU PMHNP, FNP (NPI 1023100575)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023100575 NPI number — RANDINE D NADEAU PMHNP, FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NADEAU
Provider First Name:
RANDINE
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PMHNP, FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PUTZ
Provider Other First Name:
RANDINE
Provider Other Middle Name:
D
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:
1023100575
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/21/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3835 N FREEWAY BLVD STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SACRAMENTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95834-1954
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
855-501-1004
Provider Business Mailing Address Fax Number:
866-279-1549

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4 DOCTORS PARK STE H
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ASHEVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28801-4523
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
855-501-1004
Provider Business Practice Location Address Fax Number:
866-279-1549
Provider Enumeration Date:
09/29/2006

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: 363LP0808X , with the licence number:  5001115 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 6113110 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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