Provider Demographics
NPI:1093469033
Name:ILUEBBEY, GOODIE O (REGISTERED NURSE)
Entity Type:Individual
Prefix:
First Name:GOODIE
Middle Name:O
Last Name:ILUEBBEY
Suffix:
Gender:M
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8000 MORGAN CIR N
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55444-1614
Mailing Address - Country:US
Mailing Address - Phone:763-221-4774
Mailing Address - Fax:
Practice Address - Street 1:8000 MORGAN CIR N
Practice Address - Street 2:
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55444-1614
Practice Address - Country:US
Practice Address - Phone:763-221-4774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-08
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR138523-2163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management