Provider Demographics
NPI:1437888138
Name:BOUCHILLON, RANDI NICOLE (CRNP, FNP-C)
Entity Type:Individual
Prefix:
First Name:RANDI
Middle Name:NICOLE
Last Name:BOUCHILLON
Suffix:
Gender:F
Credentials:CRNP, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44980 HAMPTONS BLVD APT 312
Mailing Address - Street 2:
Mailing Address - City:LEONARDTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20650-4753
Mailing Address - Country:US
Mailing Address - Phone:239-770-0497
Mailing Address - Fax:
Practice Address - Street 1:12807 OLD FORT RD
Practice Address - Street 2:
Practice Address - City:FORT WASHINGTON
Practice Address - State:MD
Practice Address - Zip Code:20744-2876
Practice Address - Country:US
Practice Address - Phone:301-292-7400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-08
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR244896163WP0200X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WP0200XNursing Service ProvidersRegistered NursePediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDR244896OtherRN