Provider Demographics
NPI:1447992755
Name:RANDALL, KELSEY NICOLE (RDMS)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:NICOLE
Last Name:RANDALL
Suffix:
Gender:F
Credentials:RDMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1247
Mailing Address - Street 2:
Mailing Address - City:PINE
Mailing Address - State:AZ
Mailing Address - Zip Code:85544-1247
Mailing Address - Country:US
Mailing Address - Phone:928-595-2213
Mailing Address - Fax:
Practice Address - Street 1:414 S BEELINE HWY STE 2
Practice Address - Street 2:
Practice Address - City:PAYSON
Practice Address - State:AZ
Practice Address - Zip Code:85541-4884
Practice Address - Country:US
Practice Address - Phone:928-474-3582
Practice Address - Fax:928-832-1310
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-08
Last Update Date:2022-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2018912471S1302X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2471S1302XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistSonographyGroup - Single Specialty