Provider Demographics
NPI:1437897196
Name:RANDOLPH, SYLVIA REGINA
Entity Type:Individual
Prefix:
First Name:SYLVIA
Middle Name:REGINA
Last Name:RANDOLPH
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 1:209 TRAIL WINDS DR
Mailing Address - Street 2:
Mailing Address - City:BETHLEHEM
Mailing Address - State:GA
Mailing Address - Zip Code:30620-1844
Mailing Address - Country:US
Mailing Address - Phone:678-368-9578
Mailing Address - Fax:
Practice Address - Street 1:209 TRAIL WINDS DR
Practice Address - Street 2:
Practice Address - City:BETHLEHEM
Practice Address - State:GA
Practice Address - Zip Code:30620-1844
Practice Address - Country:US
Practice Address - Phone:678-368-9578
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-23
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA055892717172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty