Basic Information
| Provider Information | |||||||||
| NPI: | 1104240035 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RANDOLL | ||||||||
| FirstName: | LESLEY | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 391 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | KISSIMMEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347445271 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4075181074 | ||||||||
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| Practice Location | |||||||||
| Address1: | 391 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | KISSIMMEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347445271 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4075181074 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2014 | ||||||||
| LastUpdateDate: | 04/28/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP2300X | APRN11002450 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care | 363LX0001X | APRN11002450 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Obstetrics & Gynecology | 364SA2200X | 2014003661 | MO | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Adult Health | 364SG0600X | 2014003661 | MO | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Gerontology | 363LG0600X | APRN11002450 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
ID Information
| ID | Type | State | Issuer | Description | 2014003661 | 01 | MO | BOARD OF NURSING LICENSE | OTHER | APRN11002450 | 01 | FL | BOARD OF NURSING LICENSE | OTHER |