=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134795214
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RANDY READ PMHNP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/31/2021
-----------------------------------------------------
Last Update Date | 03/18/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 116 HILL POND LN
-----------------------------------------------------
City | STATESBORO
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30458-0872
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-489-1629
-----------------------------------------------------
Fax | 912-489-1630
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 116 HILL POND LN
-----------------------------------------------------
City | STATESBORO
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30458-0872
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-489-1629
-----------------------------------------------------
Fax | 912-489-1630
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | RN264103
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | MR6510328
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------