Provider Demographics
NPI:1235679879
Name:RANDLE, LEILA
Entity Type:Individual
Prefix:
First Name:LEILA
Middle Name:
Last Name:RANDLE
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 1:3441 S GLASGOW CIR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-7902
Mailing Address - Country:US
Mailing Address - Phone:812-822-0228
Mailing Address - Fax:
Practice Address - Street 1:3441 S GLASGOW CIR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-7902
Practice Address - Country:US
Practice Address - Phone:812-822-0228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-01
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN8932-53-0103172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN$$$$$$$$$Medicaid