Provider Demographics
NPI:1700901881
Name:RANDOLPH, KATHERINE G (LMT)
Entity Type:Individual
Prefix:MS
First Name:KATHERINE
Middle Name:G
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2319 SPRING OAKS CIR
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34234-4962
Mailing Address - Country:US
Mailing Address - Phone:941-360-9846
Mailing Address - Fax:
Practice Address - Street 1:4801 SWIFT RD
Practice Address - Street 2:SUITE I
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34231-5139
Practice Address - Country:US
Practice Address - Phone:941-320-3391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA32332174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC7448OtherBLUE CROSS BLUE SHIELD