MEDICARE: NICOLE SUMMER RANDALL PT, DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist
2	225100000X	Physical Therapist	37524	FL

General Provider Information

NPI Number	:	1003584616
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE SUMMER RANDALL PT, DPT

Provider Business Mailing Address
First Line	:	2699 LEE RD STE 330
Second Line	:
City	:	WINTER PARK
State	:	FL
Zip	:	32789-1740
Country	:	US
Telephone Number	:	800-251-8998
Fax Number	:

Provider Business Practice Location Address
First Line	:	3909 S SUMMERLIN AVE
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32806-6905
Country	:	US
Telephone Number	:	407-317-3200
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/31/2021
Last Update Date	:	08/31/2021

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