Healthcare Provider Details

I. General information

NPI: 1972654770
Provider Name (Legal Business Name): KEVIN RANDEL SEALE CRNA-APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 06/06/2025
Certification Date: 06/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

317 WESTERN BLVD
JACKSONVILLE NC
28546-6338
US

IV. Provider business mailing address

200 MEMORIAL DR
JACKSONVILLE NC
28546-6332
US

V. Phone/Fax

Practice location:
  • Phone: 910-577-2345
  • Fax:
Mailing address:
  • Phone: 910-577-4703
  • Fax: 910-577-6257

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number75544
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: