Provider Demographics
NPI:1396367926
Name:RANDALL, NICOLE MICHELLE (SLPA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MICHELLE
Last Name:RANDALL
Suffix:
Gender:F
Credentials:SLPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:728A S LAGO DR
Mailing Address - Street 2:
Mailing Address - City:APACHE JUNCTION
Mailing Address - State:AZ
Mailing Address - Zip Code:85120-5124
Mailing Address - Country:US
Mailing Address - Phone:480-241-0788
Mailing Address - Fax:
Practice Address - Street 1:375 S COLUMBUS DR
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85296-2101
Practice Address - Country:US
Practice Address - Phone:480-507-1624
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-18
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPA157892355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant