Provider Demographics
NPI:1073281135
Name:GOODMAN, CHANNA TERESE (RN)
Entity Type:Individual
Prefix:
First Name:CHANNA
Middle Name:TERESE
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:CHANNA
Other - Middle Name:
Other - Last Name:ROYAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:100 E FERGUSON ST STE 608
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75702-5756
Mailing Address - Country:US
Mailing Address - Phone:903-705-0070
Mailing Address - Fax:
Practice Address - Street 1:100 E FERGUSON ST STE 608
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-5756
Practice Address - Country:US
Practice Address - Phone:903-705-0070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-02
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX896590163WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0200XNursing Service ProvidersRegistered NursePediatrics