Healthcare Provider Details

I. General information

NPI: 1548158538
Provider Name (Legal Business Name): SHEYENNE IMANI RANDOLPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2025
Last Update Date: 06/26/2025
Certification Date: 06/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

214 FAIRWAY DR
FAYETTEVILLE NC
28305-5502
US

IV. Provider business mailing address

1309 DUNCAN ST
FAYETTEVILLE NC
28303-3724
US

V. Phone/Fax

Practice location:
  • Phone: 910-491-8186
  • Fax:
Mailing address:
  • Phone: 910-229-1382
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number171M00000X
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: