Provider Demographics
NPI:1558559393
Name:RANDOLPH, JENNIFER LYNN (CRNA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1252
Mailing Address - Street 2:
Mailing Address - City:MURFREESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37133-1252
Mailing Address - Country:US
Mailing Address - Phone:615-396-4464
Mailing Address - Fax:615-396-6748
Practice Address - Street 1:1800 MEDICAL CENTER PKWY
Practice Address - Street 2:SUITE 330
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37129-2567
Practice Address - Country:US
Practice Address - Phone:615-396-4464
Practice Address - Fax:615-396-6748
Is Sole Proprietor?:No
Enumeration Date:2007-10-05
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN139779367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4182624OtherBCBS EFFECTIVE 5/1/08
TN3600189OtherRAIL ROAD MEDICARE
4177349OtherBLUE CROSS BLUE SHIELD
TN3600189Medicaid
4177349OtherBLUE CROSS BLUE SHIELD