Provider Demographics
NPI:1275585382
Name:GOEDHART, RENAE SUE (APRN)
Entity Type:Individual
Prefix:MRS
First Name:RENAE
Middle Name:SUE
Last Name:GOEDHART
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1089
Mailing Address - Street 2:
Mailing Address - City:PAHRUMP
Mailing Address - State:NV
Mailing Address - Zip Code:89041-1089
Mailing Address - Country:US
Mailing Address - Phone:775-513-5038
Mailing Address - Fax:775-376-9966
Practice Address - Street 1:3370 S HIGHWAY 160 STE 9
Practice Address - Street 2:
Practice Address - City:PAHRUMP
Practice Address - State:NV
Practice Address - Zip Code:89048-5373
Practice Address - Country:US
Practice Address - Phone:775-513-5038
Practice Address - Fax:775-376-9966
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2018-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVAPN000597363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1275585382Medicaid
NVFW592Z (CQ328B)Medicare PIN
NV1275585382Medicaid
NV1275585382Medicaid