1124631908 NPI number — MS. JENNIFER CATHERINE RANDALL FNP

Table of content: MS. JENNIFER CATHERINE RANDALL FNP (NPI 1124631908)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124631908 NPI number — MS. JENNIFER CATHERINE RANDALL FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RANDALL
Provider First Name:
JENNIFER
Provider Middle Name:
CATHERINE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124631908
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/02/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 37189
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21297-3189
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
571-423-5699
Provider Business Mailing Address Fax Number:
571-423-5698

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11800 SUNRISE VALLEY DR STE 700
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RESTON
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
20191-5315
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-834-1473
Provider Business Practice Location Address Fax Number:
703-318-7463
Provider Enumeration Date:
08/31/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  0024179577 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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