Provider Demographics
NPI:1396478830
Name:RANDALL, VICTORIA LANE (NP)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:LANE
Last Name:RANDALL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:VICTORIA
Other - Middle Name:LANE
Other - Last Name:ORR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 4766
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71211-4766
Mailing Address - Country:US
Mailing Address - Phone:318-388-6050
Mailing Address - Fax:318-998-3017
Practice Address - Street 1:2503 BROADMOOR BLVD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-2987
Practice Address - Country:US
Practice Address - Phone:318-388-6050
Practice Address - Fax:318-998-3017
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-01
Last Update Date:2025-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM79546363LG0600X
TN36424363LG0600X
AZ316634363LG0600X
KY4021515363LG0600X
AL3-001773363LG0600X
NV878300363LG0600X
AR230019363LG0600X
TX1182767363LG0600X
COC-APN.0103663-C-NP363LG0600X
LA226274363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Single Specialty