Provider Demographics
NPI:1720244833
Name:RANDOLPH, CATHY (NP)
Entity type:Individual
Prefix:
First Name:CATHY
Middle Name:
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 1:44 LAKEWOOD ST
Mailing Address - Street 2:
Mailing Address - City:WYANDANCH
Mailing Address - State:NY
Mailing Address - Zip Code:11798-3315
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 GRANNY RD
Practice Address - Street 2:
Practice Address - City:FARMINGVILLE
Practice Address - State:NY
Practice Address - Zip Code:11738-2879
Practice Address - Country:US
Practice Address - Phone:631-696-4357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-29
Last Update Date:2024-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY554743-1163W00000X
NY403021363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse