Provider Demographics
NPI:1366851552
Name:DYNAMIC HEALTHCARE
Entity Type:Organization
Organization Name:DYNAMIC HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:BRIDGET
Authorized Official - Middle Name:
Authorized Official - Last Name:RANDOLPH
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:405-414-6002
Mailing Address - Street 1:130 EAGLE SPRING CT
Mailing Address - Street 2:SUITE A
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-7274
Mailing Address - Country:US
Mailing Address - Phone:678-616-2273
Mailing Address - Fax:
Practice Address - Street 1:130 EAGLE SPRING CT
Practice Address - Street 2:SUITE A
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-7274
Practice Address - Country:US
Practice Address - Phone:678-616-2273
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-13
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA230003363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty