Provider Demographics
NPI:1891909354
Name:RANDOLPH, JOANN K (PHD, FNP, MS, BSN)
Entity Type:Individual
Prefix:
First Name:JOANN
Middle Name:K
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:PHD, FNP, MS, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2415 AUBURN AVE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45219-2701
Mailing Address - Country:US
Mailing Address - Phone:513-221-4949
Mailing Address - Fax:513-241-4191
Practice Address - Street 1:4027 EASTERN AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45226-1747
Practice Address - Country:US
Practice Address - Phone:513-321-2202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP-09144363LA2200X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
2031432Medicare PIN
2031434Medicare PIN
2031433Medicare PIN