Basic Information
| Provider Information | |||||||||
| NPI: | 1013587948 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RANDALL | ||||||||
| FirstName: | DENISE | ||||||||
| MiddleName: | ROCHELLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3909 ELLENBORO AVE | ||||||||
| Address2: | |||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953571443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2094090977 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7225 E SOUTHGATE DR STE D | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958232651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9163941000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2021 | ||||||||
| LastUpdateDate: | 07/01/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164X00000X | 712378 | CA | Y | Nursing Service Providers | Licensed Vocational Nurse |
No ID Information.