Provider Demographics
NPI:1346355583
Name:RANDALL, GLYNNIS D (FNP)
Entity Type:Individual
Prefix:MRS
First Name:GLYNNIS
Middle Name:D
Last Name:RANDALL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1007
Mailing Address - Street 2:
Mailing Address - City:LUCEDALE
Mailing Address - State:MS
Mailing Address - Zip Code:39452-1007
Mailing Address - Country:US
Mailing Address - Phone:601-947-1332
Mailing Address - Fax:601-947-1331
Practice Address - Street 1:975 HALL ST
Practice Address - Street 2:
Practice Address - City:WIGGINS
Practice Address - State:MS
Practice Address - Zip Code:39577-2107
Practice Address - Country:US
Practice Address - Phone:601-528-9119
Practice Address - Fax:601-528-9193
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2016-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR764278363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0116288Medicaid
MS302I502643Medicare PIN
MS0116288Medicaid