Provider Demographics
NPI:1649237256
Name:GOODMAN, BEVAN ALESIA
Entity Type:Individual
Prefix:MRS
First Name:BEVAN
Middle Name:ALESIA
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 1:1819 KEY BISCAYNE WAY
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218-3463
Mailing Address - Country:US
Mailing Address - Phone:904-757-9176
Mailing Address - Fax:904-757-9176
Practice Address - Street 1:1819 KEY BISCAYNE WAY
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-3463
Practice Address - Country:US
Practice Address - Phone:904-757-9176
Practice Address - Fax:904-757-9176
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor