Healthcare Provider Details

I. General information

NPI: 1457811523
Provider Name (Legal Business Name): STEPHANIE RANDOLPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2019
Last Update Date: 11/27/2023
Certification Date: 03/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2666 TIGERTAIL AVE APT 208
MIAMI FL
33133-4652
US

IV. Provider business mailing address

2666 TIGERTAIL AVE APT 208
MIAMI FL
33133-4652
US

V. Phone/Fax

Practice location:
  • Phone: 720-394-3992
  • Fax:
Mailing address:
  • Phone: 720-394-3992
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN9437331
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP145269
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: