Provider Demographics
NPI:1013948066
Name:MISKELLY, RANDLE S (APN)
Entity Type:Individual
Prefix:
First Name:RANDLE
Middle Name:S
Last Name:MISKELLY
Suffix:
Gender:M
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1306 US HIGHWAY 45 N
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:TN
Mailing Address - Zip Code:38340-4003
Mailing Address - Country:US
Mailing Address - Phone:731-989-9899
Mailing Address - Fax:731-989-3495
Practice Address - Street 1:1306 US HIGHWAY 45 N
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:TN
Practice Address - Zip Code:38340-4003
Practice Address - Country:US
Practice Address - Phone:731-989-9899
Practice Address - Fax:731-989-3495
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2011-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN11859363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3643080Medicaid
TNQ68310Medicare UPIN
TN3643080Medicare ID - Type Unspecified