Healthcare Provider Details

I. General information

NPI: 1053944017
Provider Name (Legal Business Name): SHELBY RANDOLPH DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2020
Last Update Date: 09/30/2024
Certification Date: 09/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 LINCOLN WAY
AMES IA
50014-7595
US

IV. Provider business mailing address

1215 DUFF AVE
AMES IA
50010-5469
US

V. Phone/Fax

Practice location:
  • Phone: 515-663-4824
  • Fax:
Mailing address:
  • Phone: 515-239-4400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number4263
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number096285
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: