Provider Demographics
NPI:1760882690
Name:RANDOLPH, DERRICK AARON (RN)
Entity Type:Individual
Prefix:MR
First Name:DERRICK
Middle Name:AARON
Last Name:RANDOLPH
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2030 CLEVELAND AVE S.W
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35601
Mailing Address - Country:US
Mailing Address - Phone:256-353-3501
Mailing Address - Fax:
Practice Address - Street 1:1207 7TH ST S.E.
Practice Address - Street 2:DECATUR/MORGAN HOSPITAL - PARKWAY CAMPUS
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:35601
Practice Address - Country:US
Practice Address - Phone:256-341-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-28
Last Update Date:2015-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-090988163W00000X, 390200000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program