Provider Demographics
NPI:1942060066
Name:GOODWIN, TALISHA MAXINE
Entity Type:Individual
Prefix:
First Name:TALISHA
Middle Name:MAXINE
Last Name:GOODWIN
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 1:8906 BLUE GRASS DR
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95210-4420
Mailing Address - Country:US
Mailing Address - Phone:209-279-6647
Mailing Address - Fax:
Practice Address - Street 1:8906 BLUE GRASS DR
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95210-4420
Practice Address - Country:US
Practice Address - Phone:209-279-6647
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-19
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)