Provider Demographics
NPI:1699385419
Name:RANDALL, KELSEY (FNP-BC)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:RANDALL
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:955 E KNOX RD UNIT 230
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85225-1482
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9003 E SHEA BLVD # AZ85260
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-6709
Practice Address - Country:US
Practice Address - Phone:928-607-8345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-06
Last Update Date:2020-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ243374363LF0000X
AZRN179953163WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WP0200XNursing Service ProvidersRegistered NursePediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ243374OtherCERTIFIED NURSE PRACTITIONER LICENSE NUMBER
AZ22467622OtherNATIONAL COUNCIL OF STATE BOARDS OF NURSING