Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251P0200X | Physical Therapist - Pediatrics | 10222 | CA |
NPI | 1083746705 |
---|---|
Provider Name | Mrs. Anne Willy Randall |
First Address | La Mesa, CA 91942-1947 |
Second Address | San Diego, CA 92120-3410 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 09/03/2007 |
Last Update Date | 08/07/2007 |