Provider Demographics
NPI:1316379324
Name:GOODMAN, THERESA ANNE (APRN, FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:ANNE
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:APRN, FNP-C
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:A
Other - Last Name:LASELVA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1169 EASTERN PKWY
Mailing Address - Street 2:SUITE 1111
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40217-1417
Mailing Address - Country:US
Mailing Address - Phone:502-456-4100
Mailing Address - Fax:502-459-8454
Practice Address - Street 1:1169 EASTERN PKWY
Practice Address - Street 2:SUITE 1111
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217-1417
Practice Address - Country:US
Practice Address - Phone:502-456-4100
Practice Address - Fax:502-459-8454
Is Sole Proprietor?:No
Enumeration Date:2013-07-31
Last Update Date:2014-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1104439163W00000X
KY3007914363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY50073436OtherPASSPORT
6492184OtherCIGNA
KY000000894646OtherANTHEM
KY7100301500Medicaid
KY50073436OtherPASSPORT