Provider Demographics
NPI:1497138515
Name:RANDERMANN, KELLY (APRN, FNP-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:RANDERMANN
Suffix:
Gender:F
Credentials:APRN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2122 HIGHWAY 71 S # 101
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:TX
Mailing Address - Zip Code:78934-3011
Mailing Address - Country:US
Mailing Address - Phone:979-733-0095
Mailing Address - Fax:979-733-0665
Practice Address - Street 1:2122 HIGHWAY 71 S # 101
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:TX
Practice Address - Zip Code:78934-3011
Practice Address - Country:US
Practice Address - Phone:979-733-0095
Practice Address - Fax:979-733-0665
Is Sole Proprietor?:No
Enumeration Date:2015-07-07
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP128474363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily