Provider Demographics
NPI:1508452269
Name:GOODMAN, CRYSTAL SADE
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:SADE
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 1:3201 20TH ST S APT 123
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-6529
Mailing Address - Country:US
Mailing Address - Phone:218-329-0516
Mailing Address - Fax:
Practice Address - Street 1:3201 20TH ST S APT 123
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-6529
Practice Address - Country:US
Practice Address - Phone:218-329-0516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-17
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant