Basic Information
| Provider Information | |||||||||
| NPI: | 1922352350 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RODDY | ||||||||
| FirstName: | RANDA | ||||||||
| MiddleName: | DEANNE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | YOUNGBLOOD | ||||||||
| OtherFirstName: | RANDA | ||||||||
| OtherMiddleName: | DEANNE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 155 | ||||||||
| Address2: | |||||||||
| City: | CHRISTOPHER | ||||||||
| State: | IL | ||||||||
| PostalCode: | 628220155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6187242436 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 14410 ROUTE 37 | ||||||||
| Address2: | |||||||||
| City: | JOHNSTON CITY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629513166 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189836911 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2012 | ||||||||
| LastUpdateDate: | 11/07/2012 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 041337855 | IL | Y | Nursing Service Providers | Registered Nurse |
No ID Information.