Provider Demographics
NPI:1821490830
Name:RANDOLPH, KIM (RN)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:
Other - Last Name:RANDOLPH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:703 60TH STREET CT E
Mailing Address - Street 2:SUITE K
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34208-6278
Mailing Address - Country:US
Mailing Address - Phone:941-748-6024
Mailing Address - Fax:941-748-6039
Practice Address - Street 1:703 60TH STREET CT E
Practice Address - Street 2:SUITE K
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34208-6278
Practice Address - Country:US
Practice Address - Phone:941-748-6024
Practice Address - Fax:941-748-6039
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-22
Last Update Date:2014-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN921328163W00000X, 163WC0400X, 163WD0400X, 163WH0200X, 163WH0500X, 163WI0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163WH0500XNursing Service ProvidersRegistered NurseHemodialysis
No163WI0500XNursing Service ProvidersRegistered NurseInfusion Therapy