Provider Demographics
NPI:1710553474
Name:RANDALL, JESSICA HATFIELD (CRNA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:HATFIELD
Last Name:RANDALL
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 1:465 OLD CREEK RD
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-2755
Mailing Address - Country:US
Mailing Address - Phone:205-743-8655
Mailing Address - Fax:
Practice Address - Street 1:1300 RIDENOUR BLVD NW STE 300
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30152-4402
Practice Address - Country:US
Practice Address - Phone:770-702-1806
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-02
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA133695367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered