Healthcare Provider Details

I. General information

NPI: 1417452996
Provider Name (Legal Business Name): KRISTIN RANDA DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2018
Last Update Date: 06/05/2022
Certification Date: 06/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2780 CLEVELAND AVE STE 709
FORT MYERS FL
33901-5857
US

IV. Provider business mailing address

11211 W LINCOLN AVE
WEST ALLIS WI
53227-1035
US

V. Phone/Fax

Practice location:
  • Phone: 239-343-3831
  • Fax: 239-343-2301
Mailing address:
  • Phone: 414-454-8300
  • Fax: 239-343-2301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS17784
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number72836
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: