Provider Demographics
NPI:1689176307
Name:GOODSON, ISIS ANDREA (LPN)
Entity Type:Individual
Prefix:MRS
First Name:ISIS
Middle Name:ANDREA
Last Name:GOODSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1233 MINGARY AVE
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28306-3558
Mailing Address - Country:US
Mailing Address - Phone:910-977-0703
Mailing Address - Fax:
Practice Address - Street 1:1233 MINGARY AVE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28306-3558
Practice Address - Country:US
Practice Address - Phone:910-977-0703
Practice Address - Fax:910-977-0703
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-08
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC058633164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse