Provider Demographics
NPI:1013587948
Name:RANDALL, DENISE ROCHELLE
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:ROCHELLE
Last Name:RANDALL
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 1:3909 ELLENBORO AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95357-1443
Mailing Address - Country:US
Mailing Address - Phone:209-409-0977
Mailing Address - Fax:
Practice Address - Street 1:7225 E SOUTHGATE DR STE D
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-2651
Practice Address - Country:US
Practice Address - Phone:916-394-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-01
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA712378164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse