Provider Demographics
NPI:1184079592
Name:RANDALL, SHAWNTA R
Entity type:Individual
Prefix:
First Name:SHAWNTA
Middle Name:R
Last Name:RANDALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHAWNTA
Other - Middle Name:R
Other - Last Name:FLATNESS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 31001-0698
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91110-5319
Mailing Address - Country:US
Mailing Address - Phone:602-236-1200
Mailing Address - Fax:605-200-5383
Practice Address - Street 1:4212 N 16TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-5319
Practice Address - Country:US
Practice Address - Phone:602-263-1200
Practice Address - Fax:602-200-5383
Is Sole Proprietor?:No
Enumeration Date:2016-05-04
Last Update Date:2016-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTNUR-RN-LIC-38864163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse