Healthcare Provider Details

I. General information

NPI: 1326071176
Provider Name (Legal Business Name): TERESA N RANDOLPH APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TERESA NICOLE MAY NP

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 04/10/2023
Certification Date: 04/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 STAGE COACH DR
PINEVILLE MO
64856
US

IV. Provider business mailing address

3901 PARKWAY CIR
SPRINGDALE AR
72762-6362
US

V. Phone/Fax

Practice location:
  • Phone: 479-790-8505
  • Fax: 479-587-1366
Mailing address:
  • Phone: 479-587-1700
  • Fax: 479-587-1366

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number87036
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number45975
License Number StateKS
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA003603
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: