Provider Demographics
NPI:1104145176
Name:JAMISON, RANDI NICOLE
Entity type:Individual
Prefix:MISS
First Name:RANDI
Middle Name:NICOLE
Last Name:JAMISON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2293 CHEROKEE VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-7908
Mailing Address - Country:US
Mailing Address - Phone:678-732-4467
Mailing Address - Fax:
Practice Address - Street 1:2293 CHEROKEE VALLEY DR
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-7908
Practice Address - Country:US
Practice Address - Phone:678-732-4467
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-28
Last Update Date:2010-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA223312251E00000X
GACN0028862135376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No376K00000XNursing Service Related ProvidersNurse's Aide