Basic Information
| Provider Information | |||||||||
| NPI: | 1184676975 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RANDALL | ||||||||
| FirstName: | GWENDOLYNN | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CRNA, PHD,APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 719 THOMPSON LN STE 30330 | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372044701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153223000 | ||||||||
| FaxNumber: | 3368841643 | ||||||||
| Practice Location | |||||||||
| Address1: | 3601 THE VNDERBILT CLINIC | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372322413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153223000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 01/09/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 17249 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | G3421 | 01 | FL | BCBS | OTHER |