Provider Demographics
NPI:1659960631
Name:RANDOLPH, SAMANTHA BRIANNA
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:BRIANNA
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 1:325 W ADAMS BLVD # 7166
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90007-2659
Mailing Address - Country:US
Mailing Address - Phone:817-233-8702
Mailing Address - Fax:
Practice Address - Street 1:4601 S BROADWAY
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90037-2729
Practice Address - Country:US
Practice Address - Phone:213-223-5922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-13
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program