Provider Demographics
NPI:1891264537
Name:GOEDEKER, ALYSSA ROSE
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:ROSE
Last Name:GOEDEKER
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 1:1632 JAMES DR
Mailing Address - Street 2:
Mailing Address - City:NORTH MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56003-1934
Mailing Address - Country:US
Mailing Address - Phone:507-848-1996
Mailing Address - Fax:
Practice Address - Street 1:1961 PREMIER DR STE 340
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-6839
Practice Address - Country:US
Practice Address - Phone:507-345-8591
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-23
Last Update Date:2018-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2414607163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health