Provider Demographics
NPI:1437798188
Name:GOODEN, KAYLA SIMONE
Entity Type:Individual
Prefix:MRS
First Name:KAYLA
Middle Name:SIMONE
Last Name:GOODEN
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 1:7418 BRAERIDGE WAY
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95831-4004
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7418 BRAERIDGE WAY
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95831-4004
Practice Address - Country:US
Practice Address - Phone:916-402-6211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-28
Last Update Date:2020-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1437798188OtherNEMT