Provider Demographics
NPI:1700615846
Name:CHURCHWELL, RANDALL SCOTT
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:SCOTT
Last Name:CHURCHWELL
Suffix:
Gender:M
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:205-545-5088
Mailing Address - Fax:
Practice Address - Street 1:2022 2ND AVE E
Practice Address - Street 2:
Practice Address - City:ONEONTA
Practice Address - State:AL
Practice Address - Zip Code:35121-2731
Practice Address - Country:US
Practice Address - Phone:205-625-3650
Practice Address - Fax:205-625-3638
Is Sole Proprietor?:No
Enumeration Date:2024-07-29
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-105436363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily