Healthcare Provider Details

I. General information

NPI: 1144640293
Provider Name (Legal Business Name): RANDELL PAIGE SMITH FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2014
Last Update Date: 01/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5644 MISSION CENTER RD
SAN DIEGO CA
92108-4328
US

IV. Provider business mailing address

1010 1ST ST SE STE 110
BANDON OR
97411-9301
US

V. Phone/Fax

Practice location:
  • Phone: 908-489-6214
  • Fax:
Mailing address:
  • Phone: 908-489-6214
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5720
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95002389
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number201602750NP-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: