Provider Demographics
NPI:1083746705
Name:RANDALL, ANNE WILLY (BS)
Entity Type:Individual
Prefix:MRS
First Name:ANNE
Middle Name:WILLY
Last Name:RANDALL
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5625 AZTEC DR
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-1947
Mailing Address - Country:US
Mailing Address - Phone:619-460-2562
Mailing Address - Fax:
Practice Address - Street 1:6160 MISSION GORGE RD
Practice Address - Street 2:SUITE 400
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-3410
Practice Address - Country:US
Practice Address - Phone:619-528-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA102222251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics