Provider Demographics
NPI:1003584616
Name:RANDALL, NICOLE SUMMER (PT, DPT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:SUMMER
Last Name:RANDALL
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2699 LEE RD STE 330
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-1740
Mailing Address - Country:US
Mailing Address - Phone:800-251-8998
Mailing Address - Fax:
Practice Address - Street 1:3909 S SUMMERLIN AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-6905
Practice Address - Country:US
Practice Address - Phone:407-317-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-31
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
FL37524225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist