Healthcare Provider Details

I. General information

NPI: 1720244833
Provider Name (Legal Business Name): CATHY RANDOLPH NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2008
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 GRANNY RD
FARMINGVILLE NY
11738-2879
US

IV. Provider business mailing address

1600 CALEBS PATH EXT STE 122
HAUPPAUGE NY
11788-5224
US

V. Phone/Fax

Practice location:
  • Phone: 631-994-1075
  • Fax: 631-350-0293
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number403021
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number554743-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: