Provider Demographics
NPI:1518573997
Name:GOODWIN, DIANE (LPN)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:GOODWIN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16416 HUNTMERE AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44110-1551
Mailing Address - Country:US
Mailing Address - Phone:330-313-0613
Mailing Address - Fax:
Practice Address - Street 1:16416 HUNTMERE AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44110-1551
Practice Address - Country:US
Practice Address - Phone:330-313-0613
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-21
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN.174148.MEDS-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse