Provider Demographics
NPI:1386363042
Name:RANDALL, WALTER (LN100692)
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:
Last Name:RANDALL
Suffix:
Gender:M
Credentials:LN100692
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6284
Mailing Address - Street 2:
Mailing Address - City:BRATTLEBORO
Mailing Address - State:VT
Mailing Address - Zip Code:05302-6284
Mailing Address - Country:US
Mailing Address - Phone:717-916-0995
Mailing Address - Fax:
Practice Address - Street 1:1210 MAIN ST
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MA
Practice Address - Zip Code:01083-9760
Practice Address - Country:US
Practice Address - Phone:717-916-0995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-25
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALN100692164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse