Provider Demographics
NPI:1710643705
Name:RANDALL, JILL MARIE (RN)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:MARIE
Last Name:RANDALL
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 1:1100 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:EAST AURORA
Mailing Address - State:NY
Mailing Address - Zip Code:14052-3009
Mailing Address - Country:US
Mailing Address - Phone:716-866-9943
Mailing Address - Fax:
Practice Address - Street 1:30 HUNTER LN
Practice Address - Street 2:
Practice Address - City:CAMP HILL
Practice Address - State:PA
Practice Address - Zip Code:17011-2499
Practice Address - Country:US
Practice Address - Phone:800-748-3243
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-13
Last Update Date:2021-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY487096-01163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse