Provider Demographics
NPI:1194849943
Name:RANDOLPH, KATIE BEATRIC (RN)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:BEATRIC
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4606 AUDUBON RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48224-2797
Mailing Address - Country:US
Mailing Address - Phone:313-885-6433
Mailing Address - Fax:
Practice Address - Street 1:1151 TAYLOR ST
Practice Address - Street 2:DETROIT HEALTH DEPT. - HERMAN KIEFER HEALTH COMPLEX
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-1732
Practice Address - Country:US
Practice Address - Phone:313-876-4322
Practice Address - Fax:313-876-0177
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704115117163WA2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA2000XNursing Service ProvidersRegistered NurseAdministrator