Provider Demographics
NPI:1922546464
Name:RANDOLPH, ALYSSA M (FNP-C)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:M
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5510 S EAST ST STE H
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46227-1939
Mailing Address - Country:US
Mailing Address - Phone:317-924-8425
Mailing Address - Fax:
Practice Address - Street 1:5510 S EAST ST STE H
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-1939
Practice Address - Country:US
Practice Address - Phone:317-924-8425
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-04
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71007267A363L00000X
IN28205335A163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300004667Medicaid