Provider Demographics
NPI:1942748405
Name:RANDLE, SHAKITA
Entity Type:Individual
Prefix:
First Name:SHAKITA
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 1:1005 E 4TH AVE UNIT 14
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31705-1373
Mailing Address - Country:US
Mailing Address - Phone:229-343-0391
Mailing Address - Fax:229-329-4474
Practice Address - Street 1:1005 E 4TH AVE UNIT 14
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31705-1373
Practice Address - Country:US
Practice Address - Phone:229-343-0391
Practice Address - Fax:229-329-4474
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-05
Last Update Date:2017-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAB15-000411251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health