Provider Demographics
NPI:1033134069
Name:NICHOLAS, RANDEE LYNE (DO)
Entity type:Individual
Prefix:DR
First Name:RANDEE
Middle Name:LYNE
Last Name:NICHOLAS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5100 E BROADWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85711-3762
Mailing Address - Country:US
Mailing Address - Phone:210-787-6442
Mailing Address - Fax:000-000-0000
Practice Address - Street 1:5100 E BROADWAY BLVD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85711-3762
Practice Address - Country:US
Practice Address - Phone:210-787-6442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2025-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NHEL12010207Q00000X
AZ3463207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine