Provider Demographics
NPI:1316544315
Name:GOODARZI, REZVANEH (CRNP)
Entity Type:Individual
Prefix:
First Name:REZVANEH
Middle Name:
Last Name:GOODARZI
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5450 KNOLL NORTH DR STE 260
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-2394
Mailing Address - Country:US
Mailing Address - Phone:410-964-6200
Mailing Address - Fax:
Practice Address - Street 1:5450 KNOLL NORTH DR STE 250
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-2368
Practice Address - Country:US
Practice Address - Phone:410-964-6115
Practice Address - Fax:410-964-5315
Is Sole Proprietor?:No
Enumeration Date:2020-10-03
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDF09201007363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily