Provider Demographics
NPI:1457028920
Name:RANDALL, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:RANDALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13010 METRO PKWY
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33966-4701
Mailing Address - Country:US
Mailing Address - Phone:239-561-5616
Mailing Address - Fax:
Practice Address - Street 1:13010 METRO PKWY
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33966-4701
Practice Address - Country:US
Practice Address - Phone:239-561-5616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-24
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT37690225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist