Provider Demographics
NPI:1073004842
Name:RANDOLPH, KIMBERLY LEE (CRNP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:LEE
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14448 WATER STREAM DR NW
Mailing Address - Street 2:
Mailing Address - City:HARVEST
Mailing Address - State:AL
Mailing Address - Zip Code:35749-5915
Mailing Address - Country:US
Mailing Address - Phone:256-348-5573
Mailing Address - Fax:
Practice Address - Street 1:2205 BELTLINE RD SW
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:AL
Practice Address - Zip Code:35601-3617
Practice Address - Country:US
Practice Address - Phone:256-306-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-28
Last Update Date:2018-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALF-04180370363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily