Provider Demographics
NPI:1124397864
Name:RANDALL, ALYSE (ATC)
Entity Type:Individual
Prefix:
First Name:ALYSE
Middle Name:
Last Name:RANDALL
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8100 W 78TH ST
Mailing Address - Street 2:SUITE #225
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55439-2516
Mailing Address - Country:US
Mailing Address - Phone:952-946-9777
Mailing Address - Fax:
Practice Address - Street 1:8100 W 78TH ST
Practice Address - Street 2:SUITE #225
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55439-2516
Practice Address - Country:US
Practice Address - Phone:952-946-9777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-27
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN22992255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer