Provider Demographics
NPI:1225743057
Name:GOODEN, OLIVIA GAVALA
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:GAVALA
Last Name:GOODEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 254
Mailing Address - Street 2:
Mailing Address - City:OAKWOOD
Mailing Address - State:GA
Mailing Address - Zip Code:30566-0005
Mailing Address - Country:US
Mailing Address - Phone:912-381-1388
Mailing Address - Fax:
Practice Address - Street 1:4838 TANGERINE CIR
Practice Address - Street 2:
Practice Address - City:OAKWOOD
Practice Address - State:GA
Practice Address - Zip Code:30566-2418
Practice Address - Country:US
Practice Address - Phone:912-381-1388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-16
Last Update Date:2023-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL14703374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula