Provider Demographics
NPI:1033588934
Name:RANDOLPH, CARMEN MARIA (CNA)
Entity type:Individual
Prefix:MRS
First Name:CARMEN
Middle Name:MARIA
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 W PEMBROKE AVE
Mailing Address - Street 2:N/A
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23669-3432
Mailing Address - Country:US
Mailing Address - Phone:757-763-7010
Mailing Address - Fax:757-763-7010
Practice Address - Street 1:407 W PEMBROKE AVE
Practice Address - Street 2:N/A
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23669-3432
Practice Address - Country:US
Practice Address - Phone:757-763-7010
Practice Address - Fax:757-763-7010
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-21
Last Update Date:2015-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA372600000X372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion