Provider Demographics
NPI:1619565017
Name:GOODMAN, LESLIE DAWN
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:DAWN
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 1:14430 NS 3500
Mailing Address - Street 2:
Mailing Address - City:KONAWA
Mailing Address - State:OK
Mailing Address - Zip Code:74849-4901
Mailing Address - Country:US
Mailing Address - Phone:580-925-2650
Mailing Address - Fax:
Practice Address - Street 1:14430 NS 3500
Practice Address - Street 2:
Practice Address - City:KONAWA
Practice Address - State:OK
Practice Address - Zip Code:74849-4901
Practice Address - Country:US
Practice Address - Phone:580-925-2650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-02
Last Update Date:2021-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
01OtherVALLIANT HOUSE