MEDICARE: DYNAMIC HEALTHCARE

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	363LF0000X	Family Nurse Practitioner	230003	GA

General Provider Information

NPI Number	:	1366851552
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DYNAMIC HEALTHCARE

Provider Business Mailing Address
First Line	:	130 EAGLE SPRING CT
Second Line	:	SUITE A
City	:	STOCKBRIDGE
State	:	GA
Zip	:	30281-7274
Country	:	US
Telephone Number	:	678-616-2273
Fax Number	:

Provider Business Practice Location Address
First Line	:	130 EAGLE SPRING CT
Second Line	:	SUITE A
City	:	STOCKBRIDGE
State	:	GA
Zip	:	30281-7274
Country	:	US
Telephone Number	:	678-616-2273
Fax Number	:

Authorized Official
Title or Position	:	NURSE PRACTITIONER
Name	:	BRIDGET RANDOLPH
Credential	:	NP
Telephone Number	:	405-414-6002

Provider Enumeration Date	:	08/13/2014
Last Update Date	:	08/13/2014

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Directions to “DYNAMIC HEALTHCARE ” Practice Location

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