Provider Demographics
NPI:1881159275
Name:RANDALL, MARIE A (LPN, MOBILE NOTARY)
Entity type:Individual
Prefix:MS
First Name:MARIE
Middle Name:A
Last Name:RANDALL
Suffix:
Gender:F
Credentials:LPN, MOBILE NOTARY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 WEEQUAHIC AVE # 1
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07112-1437
Mailing Address - Country:US
Mailing Address - Phone:973-757-3757
Mailing Address - Fax:
Practice Address - Street 1:304 WEEQUAHIC AVE # 1
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07112-1437
Practice Address - Country:US
Practice Address - Phone:973-757-3757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-10
Last Update Date:2019-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NP06084800164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Multi-Specialty