Provider Demographics
NPI:1194553578
Name:LOOMIS, RANDI BIANCA
Entity type:Individual
Prefix:
First Name:RANDI
Middle Name:BIANCA
Last Name:LOOMIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 BUXTON LN
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33426-7604
Mailing Address - Country:US
Mailing Address - Phone:336-978-1338
Mailing Address - Fax:
Practice Address - Street 1:951 NW 13TH ST STE 5E
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33486-2337
Practice Address - Country:US
Practice Address - Phone:561-392-1818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-25
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11034186363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner