Provider Demographics
NPI:1821749540
Name:RANDOLPH, AMANDA LUCILLE (APRN)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:LUCILLE
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:12596 US HIGHWAY 98 N
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33809-1089
Mailing Address - Country:US
Mailing Address - Phone:863-860-4500
Mailing Address - Fax:
Practice Address - Street 1:3037 LAKELAND HILLS BLVD STE 7A
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-2225
Practice Address - Country:US
Practice Address - Phone:863-860-4500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-13
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11017054363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily