Provider Demographics
NPI:1619740685
Name:GOODYEAR FAMILY NURSE PRACTICE LLC
Entity Type:Organization
Organization Name:GOODYEAR FAMILY NURSE PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:KESASI
Authorized Official - Middle Name:
Authorized Official - Last Name:MARSH
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:602-541-5790
Mailing Address - Street 1:17388 W NAVAJO ST
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-1941
Mailing Address - Country:US
Mailing Address - Phone:602-541-5790
Mailing Address - Fax:
Practice Address - Street 1:17388 W NAVAJO ST
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-1941
Practice Address - Country:US
Practice Address - Phone:602-649-5927
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-01
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care