Provider Demographics
NPI:1013534700
Name:RANDOLPH, TELETHIA
Entity Type:Individual
Prefix:
First Name:TELETHIA
Middle Name:
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7420 E 35TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46226-5880
Mailing Address - Country:US
Mailing Address - Phone:317-599-9821
Mailing Address - Fax:
Practice Address - Street 1:7420 E 35TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46226-5880
Practice Address - Country:US
Practice Address - Phone:317-599-9821
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-29
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No372500000XNursing Service Related ProvidersChore Provider
No372600000XNursing Service Related ProvidersAdult Companion
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider