Provider Demographics
NPI:1366274854
Name:RANDOLPH, KYRRAH RAE (ATS)
Entity type:Individual
Prefix:
First Name:KYRRAH
Middle Name:RAE
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:ATS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1502 NORTHBROOK DR APT 6
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-1122
Mailing Address - Country:US
Mailing Address - Phone:309-536-1199
Mailing Address - Fax:
Practice Address - Street 1:1502 NORTHBROOK DR APT 6
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-1122
Practice Address - Country:US
Practice Address - Phone:309-536-1199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-14
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer