Basic Information
| Provider Information | |||||||||
| NPI: | 1619205036 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BARBON | ||||||||
| FirstName: | RANDI | ||||||||
| MiddleName: | Y | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RN, CDE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13707 W JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | WOODSTOCK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600983188 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153371871 | ||||||||
| FaxNumber: | 8153386297 | ||||||||
| Practice Location | |||||||||
| Address1: | 360 STATION DR | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | CRYSTAL LAKE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600147978 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153562383 | ||||||||
| FaxNumber: | 8153562385 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/23/2009 | ||||||||
| LastUpdateDate: | 11/23/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WD0400X | 041249777 | IL | Y | Nursing Service Providers | Registered Nurse | Diabetes Educator |
ID Information
| ID | Type | State | Issuer | Description | 041249777 | 01 | IL | PROFESSIONAL LICENSE NUMBER | OTHER |