Provider Demographics
NPI:1265105803
Name:GOODMAN, MARY LISA (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:LISA
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4404 W BALLAST POINT BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33611-5602
Mailing Address - Country:US
Mailing Address - Phone:813-895-4727
Mailing Address - Fax:
Practice Address - Street 1:1807 SHORT BRANCH DR STE 102
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34655-4424
Practice Address - Country:US
Practice Address - Phone:727-376-3547
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-29
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11014405363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health