Provider Demographics
NPI:1487993846
Name:DAVIS, RANDIELL SUSANNE (LPN)
Entity type:Individual
Prefix:
First Name:RANDIELL
Middle Name:SUSANNE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:842 MOCCASIN TRL
Mailing Address - Street 2:
Mailing Address - City:XENIA
Mailing Address - State:OH
Mailing Address - Zip Code:45385-4121
Mailing Address - Country:US
Mailing Address - Phone:937-432-5356
Mailing Address - Fax:
Practice Address - Street 1:842 MOCCASIN TRL
Practice Address - Street 2:
Practice Address - City:XENIA
Practice Address - State:OH
Practice Address - Zip Code:45385-4121
Practice Address - Country:US
Practice Address - Phone:937-432-5356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-05
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN.125408 IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse