Provider Demographics
NPI:1548158538
Name:RANDOLPH, SHEYENNE IMANI
Entity type:Individual
Prefix:
First Name:SHEYENNE
Middle Name:IMANI
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 1:1309 DUNCAN ST
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28303-3724
Mailing Address - Country:US
Mailing Address - Phone:910-229-1382
Mailing Address - Fax:
Practice Address - Street 1:214 FAIRWAY DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28305-5502
Practice Address - Country:US
Practice Address - Phone:910-491-8186
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-26
Last Update Date:2025-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC171M00000X171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator