Provider Demographics
NPI:1366243982
Name:RANDALL, ANESHA MONIQUE
Entity type:Individual
Prefix:
First Name:ANESHA
Middle Name:MONIQUE
Last Name:RANDALL
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 1:603 HATTIE ST
Mailing Address - Street 2:
Mailing Address - City:SCHENECTADY
Mailing Address - State:NY
Mailing Address - Zip Code:12308-2209
Mailing Address - Country:US
Mailing Address - Phone:518-698-5572
Mailing Address - Fax:
Practice Address - Street 1:603 HATTIE ST
Practice Address - Street 2:
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12308-2209
Practice Address - Country:US
Practice Address - Phone:518-698-5572
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-20
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1882609251174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist