Provider Demographics
NPI:1386201762
Name:GOODMAN, SHONDESHA
Entity Type:Individual
Prefix:
First Name:SHONDESHA
Middle Name:
Last Name:GOODMAN
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 1:612 ASHLEY AVE
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-5904
Mailing Address - Country:US
Mailing Address - Phone:757-371-6533
Mailing Address - Fax:757-809-0691
Practice Address - Street 1:612 ASHLEY AVE
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-5904
Practice Address - Country:US
Practice Address - Phone:757-371-6533
Practice Address - Fax:757-809-0691
Is Sole Proprietor?:No
Enumeration Date:2019-05-21
Last Update Date:2019-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0031010685376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA824529499Medicaid