Provider Demographics
NPI:1174217632
Name:RANDALL, EVA (LPN)
Entity type:Individual
Prefix:
First Name:EVA
Middle Name:
Last Name:RANDALL
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:928 E 220TH ST APT 2
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10469-1054
Mailing Address - Country:US
Mailing Address - Phone:732-277-9250
Mailing Address - Fax:
Practice Address - Street 1:928 E 220TH ST APT 2
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10469-1054
Practice Address - Country:US
Practice Address - Phone:732-277-9250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-07
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY314074164W00000X
FLRN9629883163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Multi-Specialty
No163WG0000XNursing Service ProvidersRegistered NurseGeneral PracticeGroup - Multi-Specialty