Provider Demographics
NPI:1376776344
Name:RANDOLPH, DIANE R (FNP-BC)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:R
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3600 GASTON AVE
Mailing Address - Street 2:SUITE 651
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75246-1800
Mailing Address - Country:US
Mailing Address - Phone:214-820-8500
Mailing Address - Fax:214-820-8168
Practice Address - Street 1:3600 GASTON AVE
Practice Address - Street 2:SUITE 651
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-1800
Practice Address - Country:US
Practice Address - Phone:214-820-8500
Practice Address - Fax:214-820-8168
Is Sole Proprietor?:No
Enumeration Date:2009-08-25
Last Update Date:2010-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX243698363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX205998201Medicaid
TX205998202Medicaid
TX8L18521Medicare PIN
TX8L18522Medicare PIN
TX8L18550Medicare PIN