Provider Demographics
NPI:1497549497
Name:RANDALL, CHANDLER GRACE
Entity type:Individual
Prefix:
First Name:CHANDLER
Middle Name:GRACE
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 1:549 FAIR ST # 61-22
Mailing Address - Street 2:
Mailing Address - City:BLOOMSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17815-1419
Mailing Address - Country:US
Mailing Address - Phone:570-416-1925
Mailing Address - Fax:570-387-2258
Practice Address - Street 1:549 FAIR ST # 61-22
Practice Address - Street 2:
Practice Address - City:BLOOMSBURG
Practice Address - State:PA
Practice Address - Zip Code:17815-1419
Practice Address - Country:US
Practice Address - Phone:570-416-1925
Practice Address - Fax:570-387-2258
Is Sole Proprietor?:No
Enumeration Date:2025-04-07
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program