Provider Demographics
NPI:1649364084
Name:RANDALL, DONNA LEE (PT)
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:LEE
Last Name:RANDALL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:795 SALINAS AVENUE
Mailing Address - Street 2:
Mailing Address - City:TEMPLETON
Mailing Address - State:CA
Mailing Address - Zip Code:93465
Mailing Address - Country:US
Mailing Address - Phone:805-459-2117
Mailing Address - Fax:
Practice Address - Street 1:1414 PARK STREET
Practice Address - Street 2:
Practice Address - City:PASO ROBLES
Practice Address - State:CA
Practice Address - Zip Code:93446
Practice Address - Country:US
Practice Address - Phone:805-237-0272
Practice Address - Fax:805-237-2416
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT25482225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT25482AMedicare ID - Type Unspecified