Provider Demographics
NPI:1972257434
Name:RANDOLPH, KRISTIN
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4765 FAIRWAYS LN
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:GA
Mailing Address - Zip Code:30549-8836
Mailing Address - Country:US
Mailing Address - Phone:770-654-3532
Mailing Address - Fax:
Practice Address - Street 1:103 JESSE JEWELL PKWY SW
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-4321
Practice Address - Country:US
Practice Address - Phone:866-389-2727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-03
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN257493363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily