MEDICARE: MRS. KELLEY M RANDOLPH 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	363L00000X	Nurse Practitioner	80032	KS

General Provider Information

NPI Number	:	1942863915
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KELLEY M RANDOLPH APRN

Provider Business Mailing Address
First Line	:	2655 SW WANAMAKER RD STE H
Second Line	:
City	:	TOPEKA
State	:	KS
Zip	:	66614-4477
Country	:	US
Telephone Number	:	785-354-9591
Fax Number	:	785-783-8026

Provider Business Practice Location Address
First Line	:	2655 SW WANAMAKER RD STE H
Second Line	:
City	:	TOPEKA
State	:	KS
Zip	:	66614-4477
Country	:	US
Telephone Number	:	785-408-5228
Fax Number	:	785-783-8026

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

Provider Enumeration Date	:	04/16/2019
Last Update Date	:	11/18/2024

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