Provider Demographics
NPI:1720246937
Name:RANDOLPH, MARY (APN-C)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:APN-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3826 BAYSHORE RD
Mailing Address - Street 2:
Mailing Address - City:N CAPE MAY
Mailing Address - State:NJ
Mailing Address - Zip Code:08204-3208
Mailing Address - Country:US
Mailing Address - Phone:609-886-3636
Mailing Address - Fax:
Practice Address - Street 1:3826 BAYSHORE RD
Practice Address - Street 2:
Practice Address - City:N CAPE MAY
Practice Address - State:NJ
Practice Address - Zip Code:08204-3208
Practice Address - Country:US
Practice Address - Phone:609-886-3636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-26
Last Update Date:2008-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00090200363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health