Provider Demographics
NPI:1760981039
Name:RANDALL, BREANNE (PNP)
Entity Type:Individual
Prefix:MRS
First Name:BREANNE
Middle Name:
Last Name:RANDALL
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2602 WOOD RIVER PKWY
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-6418
Mailing Address - Country:US
Mailing Address - Phone:214-500-8041
Mailing Address - Fax:
Practice Address - Street 1:3000 S HULEN ST STE 180
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76109-1933
Practice Address - Country:US
Practice Address - Phone:817-750-7334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-01
Last Update Date:2018-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP135427363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics