Healthcare Provider Details

I. General information

NPI: 1619226834
Provider Name (Legal Business Name): MARJAY GLADYS RANDALL CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARJAY G JACKSON CNP

II. Dates (important events)

Enumeration Date: 09/04/2012
Last Update Date: 02/08/2023
Certification Date: 02/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3620 HOWELL FERRY RD
DULUTH GA
30096-3178
US

IV. Provider business mailing address

3620 HOWELL FERRY RD
DULUTH GA
30096-3178
US

V. Phone/Fax

Practice location:
  • Phone: 678-312-6800
  • Fax: 678-312-3282
Mailing address:
  • Phone: 678-312-6800
  • Fax: 678-312-3282

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN178428
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN178428
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: