Provider Demographics
NPI:1144640293
Name:SMITH, RANDELL PAIGE (FNP-BC)
Entity type:Individual
Prefix:MS
First Name:RANDELL
Middle Name:PAIGE
Last Name:SMITH
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 1ST ST SE
Mailing Address - Street 2:STE 110
Mailing Address - City:BANDON
Mailing Address - State:OR
Mailing Address - Zip Code:97411-9301
Mailing Address - Country:US
Mailing Address - Phone:908-489-6214
Mailing Address - Fax:
Practice Address - Street 1:5644 MISSION CENTER RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-4328
Practice Address - Country:US
Practice Address - Phone:908-489-6214
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-16
Last Update Date:2018-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5720363LF0000X
CA95002389363LF0000X
OR201602750NP-PP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily