Healthcare Provider Details

I. General information

NPI: 1013029735
Provider Name (Legal Business Name): RANDALL E WILEY DC, MSN, ARNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 04/22/2025
Certification Date: 04/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23511 HOLLYWOOD RD STE 2
LEONARDTOWN MD
20650-5922
US

IV. Provider business mailing address

23511 HOLLYWOOD RD STE 2
LEONARDTOWN MD
20650-5922
US

V. Phone/Fax

Practice location:
  • Phone: 301-997-0611
  • Fax: 855-253-1610
Mailing address:
  • Phone: 301-997-0611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR268981
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberR268981
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number0104556249
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: