MEDICARE: COURTNEY RANDALL APRN

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	363LA2200X	Adult Health Nurse Practitioner	APRN9328420	FL

General Provider Information

NPI Number	:	1023782612
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COURTNEY RANDALL APRN

Provider Business Mailing Address
First Line	:	11627 SWEET TANGERINE LN
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33626-5107
Country	:	US
Telephone Number	:	813-545-7251
Fax Number	:

Provider Business Practice Location Address
First Line	:	11627 SWEET TANGERINE LN
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33626-5107
Country	:	US
Telephone Number	:	813-545-7251
Fax Number	:

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

Provider Enumeration Date	:	08/06/2021
Last Update Date	:	08/06/2021

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