Provider Demographics
NPI:1013646579
Name:RANDULIC, SHELBY
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:
Last Name:RANDULIC
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 1:9400 LAKEVIEW RD NE
Mailing Address - Street 2:
Mailing Address - City:MINERAL CITY
Mailing Address - State:OH
Mailing Address - Zip Code:44656-9079
Mailing Address - Country:US
Mailing Address - Phone:330-340-9640
Mailing Address - Fax:
Practice Address - Street 1:659 BOULEVARD ST
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:OH
Practice Address - Zip Code:44622-2026
Practice Address - Country:US
Practice Address - Phone:330-343-3311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-08
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP0031382363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner