Provider Demographics
NPI:1750645487
Name:GOLDMON, DEBRA C (MS RD LD)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:C
Last Name:GOLDMON
Suffix:
Gender:F
Credentials:MS RD LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 SANDY BAYOU LN
Mailing Address - Street 2:
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71603-6555
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:420 SANDY BAYOU LN
Practice Address - Street 2:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-6555
Practice Address - Country:US
Practice Address - Phone:870-850-0351
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-27
Last Update Date:2012-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR0311133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered