Provider Demographics
NPI:1609497478
Name:RANDOLPH, BRENDA MARIE (RN)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:MARIE
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:RN
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 346
Mailing Address - Street 2:
Mailing Address - City:TOWNVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29689-0346
Mailing Address - Country:US
Mailing Address - Phone:864-356-3182
Mailing Address - Fax:
Practice Address - Street 1:200 UNIVERSITY RDG
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29601-3635
Practice Address - Country:US
Practice Address - Phone:864-356-3182
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-02
Last Update Date:2020-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC26913163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse