Provider Demographics
NPI:1184676975
Name:JOHNSON RANDALL, GWENDOLYNN DELORES (CRNA, PHD,APRN)
Entity Type:Individual
Prefix:DR
First Name:GWENDOLYNN
Middle Name:DELORES
Last Name:JOHNSON RANDALL
Suffix:
Gender:F
Credentials:CRNA, PHD,APRN
Other - Prefix:DR
Other - First Name:GWENDOLYNN
Other - Middle Name:DELORES
Other - Last Name:RANDALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:104 SUFFOLK DR
Mailing Address - Street 2:
Mailing Address - City:ROYAL PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33411-8262
Mailing Address - Country:US
Mailing Address - Phone:561-628-1930
Mailing Address - Fax:
Practice Address - Street 1:1000 36TH ST
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-4862
Practice Address - Country:US
Practice Address - Phone:772-776-9621
Practice Address - Fax:772-778-3494
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN17249367500000X
FL3034802367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG3421OtherBCBS
FLE8972VMedicare ID - Type Unspecified