Provider Demographics
NPI:1194095190
Name:CHAMPAGNE, EARLIS RANDALL (RN)
Entity type:Individual
Prefix:
First Name:EARLIS
Middle Name:RANDALL
Last Name:CHAMPAGNE
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1665 OLD HOT SPRINGS RD
Mailing Address - Street 2:SUITE 157
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89706-0782
Mailing Address - Country:US
Mailing Address - Phone:775-687-5162
Mailing Address - Fax:775-687-5745
Practice Address - Street 1:1528 US HIGHWAY 395 N
Practice Address - Street 2:SUITE 100
Practice Address - City:GARDNERVILLE
Practice Address - State:NV
Practice Address - Zip Code:89410-5265
Practice Address - Country:US
Practice Address - Phone:775-782-3671
Practice Address - Fax:775-782-6639
Is Sole Proprietor?:No
Enumeration Date:2012-01-06
Last Update Date:2012-01-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NVTRN 332256163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse