Provider Demographics
NPI:1790043792
Name:RANDALL, JAMIE L (FNP, PMHNP)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:L
Last Name:RANDALL
Suffix:
Gender:F
Credentials:FNP, PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 100
Mailing Address - Street 2:
Mailing Address - City:PIERCE CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65723-2100
Mailing Address - Country:US
Mailing Address - Phone:417-476-1000
Mailing Address - Fax:
Practice Address - Street 1:411 3RD ST
Practice Address - Street 2:
Practice Address - City:MONETT
Practice Address - State:MO
Practice Address - Zip Code:65708-2008
Practice Address - Country:US
Practice Address - Phone:417-235-6610
Practice Address - Fax:417-354-0065
Is Sole Proprietor?:No
Enumeration Date:2012-04-26
Last Update Date:2018-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012011476363LF0000X
MO2017001301363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOPENDINGMedicare PIN