Basic Information
| Provider Information | |||||||||
| NPI: | 1689664104 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RANDALL | ||||||||
| FirstName: | ZELMA | ||||||||
| MiddleName: | KATHERINE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | FNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DICHARRY | ||||||||
| OtherFirstName: | ZELMA | ||||||||
| OtherMiddleName: | KATHERINE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | P. O. BOX 395 | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | LA | ||||||||
| PostalCode: | 707223210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2259685292 | ||||||||
| FaxNumber: | 2256833411 | ||||||||
| Practice Location | |||||||||
| Address1: | 11990 JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | LA | ||||||||
| PostalCode: | 707223210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2259685292 | ||||||||
| FaxNumber: | 2256833411 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2005 | ||||||||
| LastUpdateDate: | 05/22/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 325141986 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 1995827 | 05 | LA | MEDICAID |