=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609378991
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RANDOLPH DIABETES AND WELLNESS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/02/2018
-----------------------------------------------------
Last Update Date | 05/12/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13047 W LINEBAUGH AVE STE 102
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33626-4487
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-475-6542
-----------------------------------------------------
Fax | 813-475-6874
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13047 W LINEBAUGH AVE STE 102
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33626-4487
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-475-6542
-----------------------------------------------------
Fax | 813-475-6874
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/MANAGER
-----------------------------------------------------
Name | MS. KIMBERLY T RANDOLPH
-----------------------------------------------------
Credential | APRN-C
-----------------------------------------------------
Telephone | 813-846-7698
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | ARNP9318390
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207QA0505X
-----------------------------------------------------
Taxonomy Name | Adult Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------