Provider Demographics
NPI:1114350923
Name:RANDAZZO, GLENNIS (GLENNIS RANDAZZO)
Entity Type:Individual
Prefix:
First Name:GLENNIS
Middle Name:
Last Name:RANDAZZO
Suffix:
Gender:F
Credentials:GLENNIS RANDAZZO
Other - Prefix:
Other - First Name:GLENNIS
Other - Middle Name:
Other - Last Name:RANDAZZO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:GLENNIS RANDAZZO
Mailing Address - Street 1:43 MORGANS COVE DR
Mailing Address - Street 2:
Mailing Address - City:ISLE OF PALMS
Mailing Address - State:SC
Mailing Address - Zip Code:29451-2667
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:43 MORGANS COVE DR
Practice Address - Street 2:
Practice Address - City:ISLE OF PALMS
Practice Address - State:SC
Practice Address - Zip Code:29451-2667
Practice Address - Country:US
Practice Address - Phone:201-213-0636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-15
Last Update Date:2013-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCR106222163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool