Provider Demographics
NPI:1013499573
Name:GOODFELLOW, TAYLOR RAY (LVN)
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:RAY
Last Name:GOODFELLOW
Suffix:
Gender:M
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 N UTICA AVE APT 518C
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79416-3034
Mailing Address - Country:US
Mailing Address - Phone:806-216-0611
Mailing Address - Fax:
Practice Address - Street 1:1303 82ND ST STE 150
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79423-2766
Practice Address - Country:US
Practice Address - Phone:806-687-3124
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-31
Last Update Date:2018-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX312930164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse