Provider Demographics
NPI:1326071176
Name:RANDOLPH, TERESA N (APRN)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:N
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:TERESA
Other - Middle Name:NICOLE
Other - Last Name:MAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:3901 PARKWAY CIR
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72762-6362
Mailing Address - Country:US
Mailing Address - Phone:479-587-1700
Mailing Address - Fax:479-587-1366
Practice Address - Street 1:220 STAGE COACH DR
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:MO
Practice Address - Zip Code:64856
Practice Address - Country:US
Practice Address - Phone:479-790-8505
Practice Address - Fax:479-587-1366
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK87036363LF0000X
KS45975363LF0000X
ARA003603363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK0087036OtherARNP LICENSE
OK200048950AMedicaid
OKOK400784Medicare PIN
OK400522518Medicare ID - Type Unspecified
OK200048950AMedicaid