Provider Demographics
NPI:1033134069
Name:NICHOLAS, RANDEE LYNE (DO)
Entity Type:Individual
Prefix:DR
First Name:RANDEE
Middle Name:LYNE
Last Name:NICHOLAS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 BERGQUIST DR STE 1
Mailing Address - Street 2:ATTN: CREDENTIALS CMC LACKLAND AFB
Mailing Address - City:LACKLAND A F B
Mailing Address - State:TX
Mailing Address - Zip Code:78236-9908
Mailing Address - Country:US
Mailing Address - Phone:210-945-7177
Mailing Address - Fax:
Practice Address - Street 1:273 COUNTY RD
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:NH
Practice Address - Zip Code:03257-5736
Practice Address - Country:US
Practice Address - Phone:603-526-2911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NHEL12010207Q00000X
AZ3463207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine