Provider Demographics
NPI:1225353873
Name:GOODMAN, ELYSE (NP)
Entity Type:Individual
Prefix:MS
First Name:ELYSE
Middle Name:
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:148 LINDEN ST
Mailing Address - Street 2:SUITE 208
Mailing Address - City:WELLESLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02482-7900
Mailing Address - Country:US
Mailing Address - Phone:781-239-0290
Mailing Address - Fax:781-235-6819
Practice Address - Street 1:148 LINDEN ST
Practice Address - Street 2:SUITE 208
Practice Address - City:WELLESLEY
Practice Address - State:MA
Practice Address - Zip Code:02482-7900
Practice Address - Country:US
Practice Address - Phone:781-239-0290
Practice Address - Fax:781-235-6819
Is Sole Proprietor?:No
Enumeration Date:2010-04-06
Last Update Date:2010-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA207099363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health