=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043677180
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MAURA E. RANDLE FNP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/20/2016
-----------------------------------------------------
Last Update Date | 12/04/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 710 W LEUDA ST
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76104-3114
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-702-5958
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5540 YELLOWSTONE RD
-----------------------------------------------------
City | THE COLONY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75056-3748
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-503-4321
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | AP129510
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------