Healthcare Provider Details

I. General information

NPI: 1003584616
Provider Name (Legal Business Name): NICOLE SUMMER RANDALL PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2021
Last Update Date: 08/31/2021
Certification Date: 08/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3909 S SUMMERLIN AVE
ORLANDO FL
32806-6905
US

IV. Provider business mailing address

2699 LEE RD STE 330
WINTER PARK FL
32789-1740
US

V. Phone/Fax

Practice location:
  • Phone: 407-317-3200
  • Fax:
Mailing address:
  • Phone: 800-251-8998
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number37524
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: