Provider Demographics
NPI:1235818295
Name:RANDOLPH, AMY MICHELLE (BSN)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:MICHELLE
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 RANDOLPH DR
Mailing Address - Street 2:
Mailing Address - City:RICE
Mailing Address - State:VA
Mailing Address - Zip Code:23966-2317
Mailing Address - Country:US
Mailing Address - Phone:434-547-0366
Mailing Address - Fax:
Practice Address - Street 1:1901 TATE SPRINGS RD
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-1109
Practice Address - Country:US
Practice Address - Phone:434-200-3642
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-17
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001269946163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse