Healthcare Provider Details

I. General information

NPI: 1104240035
Provider Name (Legal Business Name): LESLEY ANN RANDOLL APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2014
Last Update Date: 04/28/2021
Certification Date: 04/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

391 N MAIN ST
KISSIMMEE FL
34744-5271
US

IV. Provider business mailing address

391 N MAIN ST
KISSIMMEE FL
34744-5271
US

V. Phone/Fax

Practice location:
  • Phone: 407-518-1074
  • Fax:
Mailing address:
  • Phone: 407-518-1074
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberAPRN11002450
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License NumberAPRN11002450
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License Number2014003661
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code364SG0600X
TaxonomyGerontology Clinical Nurse Specialist
License Number2014003661
License Number StateMO
# 5
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAPRN11002450
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: