Provider Demographics
NPI:1720528292
Name:SIMON, RANDI MICHELLE (LPN)
Entity type:Individual
Prefix:
First Name:RANDI
Middle Name:MICHELLE
Last Name:SIMON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1029 JEFFERSON CHASE WAY
Mailing Address - Street 2:
Mailing Address - City:BLACKLICK
Mailing Address - State:OH
Mailing Address - Zip Code:43004-9156
Mailing Address - Country:US
Mailing Address - Phone:614-307-4671
Mailing Address - Fax:
Practice Address - Street 1:2065 STONERIDGE DR
Practice Address - Street 2:
Practice Address - City:CIRCLEVILLE
Practice Address - State:OH
Practice Address - Zip Code:43113-8956
Practice Address - Country:US
Practice Address - Phone:740-500-1391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-03
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH155090164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse