Provider Demographics
NPI:1598902611
Name:GOFORTH, HEATHER LEIGH (CRNA)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:LEIGH
Last Name:GOFORTH
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 840853
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-0853
Mailing Address - Country:US
Mailing Address - Phone:972-233-1999
Mailing Address - Fax:972-233-3666
Practice Address - Street 1:900 8TH AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104
Practice Address - Country:US
Practice Address - Phone:817-887-5292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-12
Last Update Date:2018-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX732401367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered