Provider Demographics
NPI:1932441565
Name:KOTAL-LEE, RANDI BLISS (NP)
Entity Type:Individual
Prefix:
First Name:RANDI
Middle Name:BLISS
Last Name:KOTAL-LEE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:390 KEOWEE SCHOOL RD
Practice Address - Street 2:
Practice Address - City:SENECA
Practice Address - State:SC
Practice Address - Zip Code:29672-6743
Practice Address - Country:US
Practice Address - Phone:864-885-7129
Practice Address - Fax:864-882-7240
Is Sole Proprietor?:No
Enumeration Date:2013-03-21
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN218154363LG0600X
SC18472363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP2705Medicaid