Provider Demographics
NPI:1174179675
Name:RANDALL, AMBER NICHOLE
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:NICHOLE
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:PO BOX 3848
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74802-3848
Mailing Address - Country:US
Mailing Address - Phone:405-570-4346
Mailing Address - Fax:405-275-5132
Practice Address - Street 1:1010 E 45TH ST
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74804-2202
Practice Address - Country:US
Practice Address - Phone:405-273-1170
Practice Address - Fax:405-275-5132
Is Sole Proprietor?:No
Enumeration Date:2019-08-12
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator