Provider Demographics
NPI:1003306267
Name:GOODMAN, KAWANA (LPN)
Entity type:Individual
Prefix:
First Name:KAWANA
Middle Name:
Last Name:GOODMAN
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 1:8216 PEAR RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32210-3474
Mailing Address - Country:US
Mailing Address - Phone:904-446-0318
Mailing Address - Fax:
Practice Address - Street 1:8216 PEAR RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210-3474
Practice Address - Country:US
Practice Address - Phone:904-446-0318
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-14
Last Update Date:2018-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL5179299164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse