Provider Demographics
NPI:1356781819
Name:HERBERT, RANDAL (FNP-C)
Entity type:Individual
Prefix:
First Name:RANDAL
Middle Name:
Last Name:HERBERT
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:RANDY
Other - Middle Name:
Other - Last Name:HERBERT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4200 IOLA ST.
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70001
Mailing Address - Country:US
Mailing Address - Phone:504-296-0777
Mailing Address - Fax:504-455-2992
Practice Address - Street 1:14116 CUSTOMS BLVD
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-5164
Practice Address - Country:US
Practice Address - Phone:601-957-6300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-28
Last Update Date:2019-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAF0613731363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily