Provider Demographics
NPI:1417689050
Name:RANDELS, MARYJANE N (FNP-ENP)
Entity Type:Individual
Prefix:
First Name:MARYJANE
Middle Name:N
Last Name:RANDELS
Suffix:
Gender:F
Credentials:FNP-ENP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1561 LENRU RD
Mailing Address - Street 2:
Mailing Address - City:BOGART
Mailing Address - State:GA
Mailing Address - Zip Code:30622-3334
Mailing Address - Country:US
Mailing Address - Phone:770-725-2399
Mailing Address - Fax:770-725-2804
Practice Address - Street 1:1561 LENRU RD
Practice Address - Street 2:SUITE A
Practice Address - City:BOGART
Practice Address - State:GA
Practice Address - Zip Code:30622
Practice Address - Country:US
Practice Address - Phone:850-445-4832
Practice Address - Fax:706-549-3138
Is Sole Proprietor?:No
Enumeration Date:2022-06-30
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGAA-NP000734363LF0000X
GAGAANP000734363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily