Provider Demographics
NPI:1558183467
Name:WILKINSON, RANDALL
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:
Last Name:WILKINSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5396 NICOLE
Mailing Address - Street 2:
Mailing Address - City:WHITE LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48383-2657
Mailing Address - Country:US
Mailing Address - Phone:248-920-4988
Mailing Address - Fax:
Practice Address - Street 1:304 LAMIER DR
Practice Address - Street 2:
Practice Address - City:WHITE LAKE
Practice Address - State:MI
Practice Address - Zip Code:48383-2630
Practice Address - Country:US
Practice Address - Phone:248-636-7965
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-30
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide