Healthcare Provider Details

I. General information

NPI: 1700740545
Provider Name (Legal Business Name): ANDRADEEN RANDALL APRN, WHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2025
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1731 MOCKINGBIRD LN
LAKELAND FL
33801-5947
US

IV. Provider business mailing address

1731 MOCKINGBIRD LN
LAKELAND FL
33801-5947
US

V. Phone/Fax

Practice location:
  • Phone: 863-272-1550
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberAPRN11043113
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: