Healthcare Provider Details

I. General information

NPI: 1366274854
Provider Name (Legal Business Name): KYRRAH RAE RANDOLPH ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2024
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 LINCOLN AVE
CHARLESTON IL
61920-3099
US

IV. Provider business mailing address

1345 GARFIELD AVE APT 1
CHARLESTON IL
61920-3795
US

V. Phone/Fax

Practice location:
  • Phone: 217-581-5000
  • Fax:
Mailing address:
  • Phone: 309-536-1199
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: