Provider Demographics
NPI:1265898365
Name:RANDLE, MARCIE JEANETTE
Entity type:Individual
Prefix:MRS
First Name:MARCIE
Middle Name:JEANETTE
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 1:10824 WADSWORTH AVE
Mailing Address - Street 2:
Mailing Address - City:GARFIELD HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44125-2256
Mailing Address - Country:US
Mailing Address - Phone:216-644-7158
Mailing Address - Fax:
Practice Address - Street 1:16004 BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:MAPLE HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44137-2575
Practice Address - Country:US
Practice Address - Phone:216-355-3991
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-06
Last Update Date:2016-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2111753374U00000X, 376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2111753Medicaid