Provider Demographics
NPI:1346990082
Name:GOODWIN, MARLISHA
Entity Type:Individual
Prefix:
First Name:MARLISHA
Middle Name:
Last Name:GOODWIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3151 SOARING GULLS DR UNIT 2199
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-7046
Mailing Address - Country:US
Mailing Address - Phone:702-472-6847
Mailing Address - Fax:
Practice Address - Street 1:3151 SOARING GULLS DR UNIT 2199
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-7046
Practice Address - Country:US
Practice Address - Phone:702-472-6847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-25
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1605134285Medicaid