Provider Demographics
NPI:1639565179
Name:GOODWIN, LATANYA
Entity Type:Individual
Prefix:MRS
First Name:LATANYA
Middle Name:
Last Name:GOODWIN
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 1:558 MISSION RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-1708
Mailing Address - Country:US
Mailing Address - Phone:502-319-0455
Mailing Address - Fax:
Practice Address - Street 1:558 MISSION RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-1708
Practice Address - Country:US
Practice Address - Phone:502-319-0455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-11
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310500000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Mental Illness