Provider Demographics
NPI:1205513942
Name:RANDOL, CHAD LARSEN (APRN)
Entity type:Individual
Prefix:
First Name:CHAD
Middle Name:LARSEN
Last Name:RANDOL
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:351 COCONUT DR
Mailing Address - Street 2:
Mailing Address - City:INDIALANTIC
Mailing Address - State:FL
Mailing Address - Zip Code:32903-3843
Mailing Address - Country:US
Mailing Address - Phone:859-428-6492
Mailing Address - Fax:
Practice Address - Street 1:351 COCONUT DR
Practice Address - Street 2:
Practice Address - City:INDIALANTIC
Practice Address - State:FL
Practice Address - Zip Code:32903-3843
Practice Address - Country:US
Practice Address - Phone:859-428-6492
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-04
Last Update Date:2023-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11027198363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily