Provider Demographics
NPI:1487278529
Name:RANDEL, MARY ANN
Entity type:Individual
Prefix:
First Name:MARY ANN
Middle Name:
Last Name:RANDEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 1ST AVE N UNIT 3
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35203-1866
Mailing Address - Country:US
Mailing Address - Phone:205-644-8256
Mailing Address - Fax:
Practice Address - Street 1:1420 NORTH BRINDLEE AVENUE
Practice Address - Street 2:SUITE A-1
Practice Address - City:ARAB
Practice Address - State:AL
Practice Address - Zip Code:35016
Practice Address - Country:US
Practice Address - Phone:256-677-4553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-04
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-166149363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily