Healthcare Provider Details

I. General information

NPI: 1295678811
Provider Name (Legal Business Name): ALEXIS RANDALL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2026
Last Update Date: 04/09/2026
Certification Date: 04/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 BEE ST
CHARLESTON SC
29425-0001
US

IV. Provider business mailing address

13512 SANDERLING PL
GERMANTOWN MD
20874-3468
US

V. Phone/Fax

Practice location:
  • Phone: 843-876-7645
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: