Provider Demographics
NPI:1548085038
Name:RANDOLPH, JESSICA CHARIS (NP)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:CHARIS
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 S BOUZIDEN DR
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-7324
Mailing Address - Country:US
Mailing Address - Phone:620-952-1546
Mailing Address - Fax:
Practice Address - Street 1:500 E THORPE ST
Practice Address - Street 2:
Practice Address - City:LAKIN
Practice Address - State:KS
Practice Address - Zip Code:67860-9625
Practice Address - Country:US
Practice Address - Phone:620-355-7111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-19
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK206118363LF0000X
KS53-83783-011363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily