Healthcare Provider Details

I. General information

NPI: 1346355583
Provider Name (Legal Business Name): GLYNNIS D RANDALL F.N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 11/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

975 HALL ST
WIGGINS MS
39577-2107
US

IV. Provider business mailing address

PO BOX 1007
LUCEDALE MS
39452-1007
US

V. Phone/Fax

Practice location:
  • Phone: 601-528-9119
  • Fax: 601-528-9193
Mailing address:
  • Phone: 601-947-1332
  • Fax: 601-947-1331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR764278
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: