Provider Demographics
NPI:1083284855
Name:RANDALL, DATRICE LESHAY
Entity Type:Individual
Prefix:
First Name:DATRICE
Middle Name:LESHAY
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 1:8064 KENSINGTON BLVD APT 171
Mailing Address - Street 2:
Mailing Address - City:DAVISON
Mailing Address - State:MI
Mailing Address - Zip Code:48423-2908
Mailing Address - Country:US
Mailing Address - Phone:313-461-6196
Mailing Address - Fax:
Practice Address - Street 1:8064 KENSINGTON BLVD APT 171
Practice Address - Street 2:
Practice Address - City:DAVISON
Practice Address - State:MI
Practice Address - Zip Code:48423-2908
Practice Address - Country:US
Practice Address - Phone:313-461-6196
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-25
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty