Provider Demographics
NPI:1417504762
Name:GOODWIN, VIVIAN LEIGH
Entity Type:Individual
Prefix:
First Name:VIVIAN
Middle Name:LEIGH
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 1:7725 JACKSON COUNTY LINE RD
Mailing Address - Street 2:
Mailing Address - City:LUCEDALE
Mailing Address - State:MS
Mailing Address - Zip Code:39452-4003
Mailing Address - Country:US
Mailing Address - Phone:228-219-3319
Mailing Address - Fax:
Practice Address - Street 1:7725 JACKSON COUNTY LINE RD
Practice Address - Street 2:
Practice Address - City:LUCEDALE
Practice Address - State:MS
Practice Address - Zip Code:39452-4003
Practice Address - Country:US
Practice Address - Phone:228-219-3319
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-21
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider