Healthcare Provider Details

I. General information

NPI: 1902304132
Provider Name (Legal Business Name): CAITLIN BERNICE MCCANN RANDALL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2018
Last Update Date: 06/29/2023
Certification Date: 09/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 ELMWOOD AVE
ROCHESTER NY
14642-0001
US

IV. Provider business mailing address

601 ELMWOOD AVE BOX 278984
ROCHESTER NY
14642-0001
US

V. Phone/Fax

Practice location:
  • Phone: 585-274-4569
  • Fax: 585-276-1543
Mailing address:
  • Phone: 585-274-4569
  • Fax: 585-276-1543

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number431220
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number431220
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number431220
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: