Provider Demographics
NPI:1306131446
Name:RANDALL, ADA PAULINE
Entity type:Individual
Prefix:
First Name:ADA
Middle Name:PAULINE
Last Name:RANDALL
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 1:648 WHITETAIL DR
Mailing Address - Street 2:
Mailing Address - City:FLEETWOOD
Mailing Address - State:NC
Mailing Address - Zip Code:28626-9280
Mailing Address - Country:US
Mailing Address - Phone:706-331-3508
Mailing Address - Fax:
Practice Address - Street 1:670 W FIREWEED LN STE 160
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503-2561
Practice Address - Country:US
Practice Address - Phone:907-770-0862
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-16
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA253763164X00000X
AK142293164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1306131446Medicaid