MEDICARE: TARA RANDALL

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	363L00000X	Nurse Practitioner	F09170149	GA

General Provider Information

NPI Number	:	1437660305
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TARA RANDALL

Provider Business Mailing Address
First Line	:	2810 TANNER LAKE TRL NW
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30064-1200
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2810 TANNER LAKE TRL NW
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30064-1200
Country	:	US
Telephone Number	:	678-516-1053
Fax Number	:

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

Provider Enumeration Date	:	10/19/2017
Last Update Date	:	10/19/2017

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Directions to “ TARA RANDALL ” Practice Location

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