Provider Demographics
NPI:1275657942
Name:GOODSPEED, TANYA M (LPN)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:M
Last Name:GOODSPEED
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2929 STATE ROUTE 49
Mailing Address - Street 2:
Mailing Address - City:BLOSSVALE
Mailing Address - State:NY
Mailing Address - Zip Code:13308-3128
Mailing Address - Country:US
Mailing Address - Phone:315-245-1873
Mailing Address - Fax:
Practice Address - Street 1:2 TERRITORY RD
Practice Address - Street 2:
Practice Address - City:ONEIDA
Practice Address - State:NY
Practice Address - Zip Code:13421-9304
Practice Address - Country:US
Practice Address - Phone:315-829-8700
Practice Address - Fax:315-829-8731
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY283985-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse