Provider Demographics
NPI:1316487234
Name:RANDALL, KELLY ANN
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:RANDALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:ANN
Other - Last Name:CORY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15802 N PARKVIEW PL
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374-7466
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15802 N PARKVIEW PL
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-7466
Practice Address - Country:US
Practice Address - Phone:623-876-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-24
Last Update Date:2017-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN196395163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse