Provider Demographics
NPI:1619226834
Name:RANDALL, MARJAY GLADYS (CNP)
Entity Type:Individual
Prefix:
First Name:MARJAY
Middle Name:GLADYS
Last Name:RANDALL
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:MARJAY
Other - Middle Name:G
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNP
Mailing Address - Street 1:3620 HOWELL FERRY RD
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-3178
Mailing Address - Country:US
Mailing Address - Phone:678-312-6800
Mailing Address - Fax:678-312-3282
Practice Address - Street 1:3620 HOWELL FERRY RD
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-3178
Practice Address - Country:US
Practice Address - Phone:678-312-6800
Practice Address - Fax:678-312-3282
Is Sole Proprietor?:No
Enumeration Date:2012-09-04
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN178428163W00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse