Provider Demographics
NPI:1275884645
Name:GOEDECKE, REBECCA LEIGH (CPNP)
Entity Type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:LEIGH
Last Name:GOEDECKE
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:LEIGH
Other - Last Name:LOONEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CPNP
Mailing Address - Street 1:6656 BOOTH FORREST CV
Mailing Address - Street 2:
Mailing Address - City:BARTLETT
Mailing Address - State:TN
Mailing Address - Zip Code:38135-9118
Mailing Address - Country:US
Mailing Address - Phone:904-705-1339
Mailing Address - Fax:
Practice Address - Street 1:51 N DUNLAP ST
Practice Address - Street 2:G145
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38105-4625
Practice Address - Country:US
Practice Address - Phone:901-287-5928
Practice Address - Fax:901-266-6455
Is Sole Proprietor?:No
Enumeration Date:2012-09-26
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9382864363LP0200X
TN19922363LP0200X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics