Basic Information
| Provider Information | |||||||||
| NPI: | 1891978763 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RANDALL | ||||||||
| FirstName: | JUDITH | ||||||||
| MiddleName: | MYRICK | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1890 WAITE ST | ||||||||
| Address2: | STE 1 | ||||||||
| City: | NORTH BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974591229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417566232 | ||||||||
| FaxNumber: | 5417566234 | ||||||||
| Practice Location | |||||||||
| Address1: | 1890 WAITE ST | ||||||||
| Address2: | STE 1 | ||||||||
| City: | NORTH BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974591229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417566232 | ||||||||
| FaxNumber: | 5417566234 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2007 | ||||||||
| LastUpdateDate: | 06/22/2012 | ||||||||
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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 | 363LF0000X | AP30007876 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 201250024 | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LP0808X | 201250025NP | OR | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 1619915113 | 01 | WATERFALL CLINIC, INC. GROUP NPI | OTHER | 213342 | 05 | OR | MEDICAID | R120353 | 01 | GROUP PTAN NUMBER | OTHER |