Provider Demographics
NPI:1508483678
Name:GOODFELLOW, GRACE N
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:N
Last Name:GOODFELLOW
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 1:365 W 1550 N STE H
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-2279
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:365 W 1550 N STE H
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-2279
Practice Address - Country:US
Practice Address - Phone:801-618-7903
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-06
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPT014683OtherPROFESSIONAL LICENSE