Provider Demographics
NPI:1134906696
Name:RANDOLPH, MELISSA JEAN (BSN, RN, IBCLC)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:JEAN
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:BSN, RN, IBCLC
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:JEAN
Other - Last Name:LONGOBARDI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:99 ASHLEY CT
Mailing Address - Street 2:
Mailing Address - City:MYERSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21773-8417
Mailing Address - Country:US
Mailing Address - Phone:717-329-3124
Mailing Address - Fax:
Practice Address - Street 1:99 ASHLEY CT
Practice Address - Street 2:
Practice Address - City:MYERSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21773-8417
Practice Address - Country:US
Practice Address - Phone:717-329-3124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-08
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR240719163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant