Provider Demographics
NPI:1003658428
Name:RANDALL, KEIRA (NP)
Entity type:Individual
Prefix:
First Name:KEIRA
Middle Name:
Last Name:RANDALL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6582 WAGON TRAIL ST
Mailing Address - Street 2:
Mailing Address - City:ZEPHYRHILLS
Mailing Address - State:FL
Mailing Address - Zip Code:33541-2556
Mailing Address - Country:US
Mailing Address - Phone:813-606-8110
Mailing Address - Fax:
Practice Address - Street 1:7105 MARINER BLVD
Practice Address - Street 2:
Practice Address - City:SPRING HILL
Practice Address - State:FL
Practice Address - Zip Code:34609-1048
Practice Address - Country:US
Practice Address - Phone:352-596-1339
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-07
Last Update Date:2024-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11033257363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health