Provider Demographics
NPI:1245076728
Name:RANDLE, TRACY RENEE
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:RENEE
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 1:17325 EUCLID AVE STE 2013
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44112-1250
Mailing Address - Country:US
Mailing Address - Phone:216-202-3381
Mailing Address - Fax:
Practice Address - Street 1:17325 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44112-1247
Practice Address - Country:US
Practice Address - Phone:216-233-9538
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-03
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN-098286M-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse