Provider Demographics
NPI:1679508626
Name:GOODWIN, MARJORIE ANN (RN-PC MA)
Entity Type:Individual
Prefix:
First Name:MARJORIE
Middle Name:ANN
Last Name:GOODWIN
Suffix:
Gender:F
Credentials:RN-PC MA
Other - Prefix:
Other - First Name:MARJORIE
Other - Middle Name:ANN
Other - Last Name:GOODWIN TUYMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN-PC MA
Mailing Address - Street 1:129 CHISWICK RD
Mailing Address - Street 2:#7
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-5314
Mailing Address - Country:US
Mailing Address - Phone:617-782-5192
Mailing Address - Fax:
Practice Address - Street 1:1132 WESTFIELD ST
Practice Address - Street 2:
Practice Address - City:WEST SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01089-3878
Practice Address - Country:US
Practice Address - Phone:413-592-1980
Practice Address - Fax:413-439-0096
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA114364364SP0813X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0813XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Geropsychiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA83-01551OtherEVERCARE
MAP00169878OtherRAIL ROAD MEDICARE
MA83-01551OtherEVERCARE
MANS0078Medicare ID - Type Unspecified