Provider Demographics
NPI:1669579025
Name:VETERANS ADMINISTRATION MEDICAL CENTER
Entity type:Organization
Organization Name:VETERANS ADMINISTRATION MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADULT NURSE PRACTITIONER
Authorized Official - Prefix:MS
Authorized Official - First Name:VERONICA
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:RANDOLPH
Authorized Official - Suffix:
Authorized Official - Credentials:NURSE PRACTITIONER
Authorized Official - Phone:301-884-7902
Mailing Address - Street 1:PO BOX 296
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MD
Mailing Address - Zip Code:20735
Mailing Address - Country:US
Mailing Address - Phone:301-996-7709
Mailing Address - Fax:301-884-7106
Practice Address - Street 1:29431 CHARLOTTE HALL ROAD
Practice Address - Street 2:VAMC CLINIC
Practice Address - City:CHARLOTTE HALL
Practice Address - State:MD
Practice Address - Zip Code:20622
Practice Address - Country:US
Practice Address - Phone:301-884-7102
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR110705261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center