Healthcare Provider Details

I. General information

NPI: 1306703822
Provider Name (Legal Business Name): RANDI LEE DETTLING PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2026
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3516 PLANK RD STE 5A
FREDERICKSBURG VA
22407-6861
US

IV. Provider business mailing address

2331 YORK RD STE 100
TIMONIUM MD
21093-2246
US

V. Phone/Fax

Practice location:
  • Phone: 667-668-2566
  • Fax:
Mailing address:
  • Phone: 667-668-2566
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110012141
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0010358
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: