Provider Demographics
NPI:1902021678
Name:GOODLAND, DEBORA KAY (RN)
Entity Type:Individual
Prefix:MRS
First Name:DEBORA
Middle Name:KAY
Last Name:GOODLAND
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4510 N 37TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85019-3206
Mailing Address - Country:US
Mailing Address - Phone:602-336-2990
Mailing Address - Fax:
Practice Address - Street 1:4510 N 37TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85019-3206
Practice Address - Country:US
Practice Address - Phone:602-336-2990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN062343163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ572926Medicaid