1912611484 NPI number — PRISCILLA MICHELLE RANDOLPH SLP

Table of content: PRISCILLA MICHELLE RANDOLPH SLP (NPI 1912611484)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912611484 NPI number — PRISCILLA MICHELLE RANDOLPH SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RANDOLPH
Provider First Name:
PRISCILLA
Provider Middle Name:
MICHELLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
SLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1912611484
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/11/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1823 TIGER FLOWERS DR NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30314-1833
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8227 MEADOWBRIDGE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MECHANICSVILLE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23116-2322
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-495-0153
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/10/2023

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 235Z00000X , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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