Provider Demographics
NPI:1962605246
Name:RANDALL, ELLEN F (LMT)
Entity type:Individual
Prefix:MR
First Name:ELLEN
Middle Name:F
Last Name:RANDALL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2929 KINGSWOOD DR
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-2049
Mailing Address - Country:US
Mailing Address - Phone:850-832-7786
Mailing Address - Fax:
Practice Address - Street 1:2629 W 23RD ST
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-2311
Practice Address - Country:US
Practice Address - Phone:850-832-7786
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA31576225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist