Healthcare Provider Details

I. General information

NPI: 1386291003
Provider Name (Legal Business Name): ROBERTA JEAN RANDALL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2019
Last Update Date: 08/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1165 AIRPORT BLVD
AUSTIN TX
78702-3152
US

IV. Provider business mailing address

1430 COLLIER ST
AUSTIN TX
78704-2911
US

V. Phone/Fax

Practice location:
  • Phone: 512-703-1365
  • Fax: 512-804-3457
Mailing address:
  • Phone: 512-440-4096
  • Fax: 512-440-4082

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number232327
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: