Provider Demographics
NPI:1871602664
Name:RANDAZZO, CONNIE MALLO (CNS)
Entity type:Individual
Prefix:MS
First Name:CONNIE
Middle Name:MALLO
Last Name:RANDAZZO
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:CONNIE
Other - Middle Name:F
Other - Last Name:MALLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2620 E PROSPECT RD
Mailing Address - Street 2:SUITE 190
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-9098
Mailing Address - Country:US
Mailing Address - Phone:970-221-1106
Mailing Address - Fax:970-232-1050
Practice Address - Street 1:2620 E PROSPECT RD
Practice Address - Street 2:SUITE 190
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-9098
Practice Address - Country:US
Practice Address - Phone:970-221-1106
Practice Address - Fax:970-232-1050
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2016-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO81170364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO87954770Medicaid
CO87954770Medicaid
CO87954770Medicaid