Basic Information
| Provider Information | |||||||||
| NPI: | 1285724625 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RANDALL | ||||||||
| FirstName: | RENITA | ||||||||
| MiddleName: | W. | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 802843 | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641802843 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4177306430 | ||||||||
| FaxNumber: | 4172697567 | ||||||||
| Practice Location | |||||||||
| Address1: | 3203 E OLD STONE RD | ||||||||
| Address2: | |||||||||
| City: | BROOKLINE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 656199620 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4172691910 | ||||||||
| FaxNumber: | 4172691916 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2006 | ||||||||
| LastUpdateDate: | 04/28/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 110109 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 427183702 | 05 | MO | MEDICAID |