Provider Demographics
NPI:1033667878
Name:RANDOL, SHANE (LPN)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:RANDOL
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1624 TIFFIN AVE
Mailing Address - Street 2:
Mailing Address - City:FINDLAY
Mailing Address - State:OH
Mailing Address - Zip Code:45840-6852
Mailing Address - Country:US
Mailing Address - Phone:419-422-7800
Mailing Address - Fax:
Practice Address - Street 1:1624 TIFFIN AVE
Practice Address - Street 2:
Practice Address - City:FINDLAY
Practice Address - State:OH
Practice Address - Zip Code:45840-6852
Practice Address - Country:US
Practice Address - Phone:419-422-7800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-21
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN.133610.MEDS-IV164W00000X
251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No251S00000XAgenciesCommunity/Behavioral Health