Provider Demographics
NPI:1144780792
Name:RANDALL, DORRIE
Entity Type:Individual
Prefix:
First Name:DORRIE
Middle Name:
Last Name:RANDALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DORRIE
Other - Middle Name:G
Other - Last Name:RANDALL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPN
Mailing Address - Street 1:2002 PLAINVIEW LANE
Mailing Address - Street 2:
Mailing Address - City:SHACKLEFORDS
Mailing Address - State:VA
Mailing Address - Zip Code:23156
Mailing Address - Country:US
Mailing Address - Phone:804-832-7885
Mailing Address - Fax:
Practice Address - Street 1:2002 PLAINVIEW LANE
Practice Address - Street 2:
Practice Address - City:SHACKLEFORDS
Practice Address - State:VA
Practice Address - Zip Code:23156
Practice Address - Country:US
Practice Address - Phone:804-832-7885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-20
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0002068137164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse