Provider Demographics
NPI:1184051963
Name:RANDOLPH, TANYA RENEE (LPN)
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:RENEE
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:626 BERNARD AVE
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37921
Mailing Address - Country:US
Mailing Address - Phone:865-522-0161
Mailing Address - Fax:865-521-7920
Practice Address - Street 1:626 BERNARD AVE
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37921
Practice Address - Country:US
Practice Address - Phone:865-522-0161
Practice Address - Fax:865-521-7920
Is Sole Proprietor?:No
Enumeration Date:2013-10-11
Last Update Date:2013-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN64954164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse