MEDICARE: SHEYENNE IMANI RANDOLPH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171M00000X	Case Manager/Care Coordinator	171M00000X	NC

General Provider Information

NPI Number	:	1548158538
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHEYENNE IMANI RANDOLPH

Provider Business Mailing Address
First Line	:	1309 DUNCAN ST
Second Line	:
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28303-3724
Country	:	US
Telephone Number	:	910-229-1382
Fax Number	:

Provider Business Practice Location Address
First Line	:	214 FAIRWAY DR
Second Line	:
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28305-5502
Country	:	US
Telephone Number	:	910-491-8186
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/26/2025
Last Update Date	:	06/26/2025

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