Provider Demographics
NPI:1336755453
Name:GOFFUS, THERESA LYNN
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:LYNN
Last Name:GOFFUS
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 1:820 N NICKELPLATE ST
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44641-2460
Mailing Address - Country:US
Mailing Address - Phone:330-412-6561
Mailing Address - Fax:
Practice Address - Street 1:820 N NICKELPLATE ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:OH
Practice Address - Zip Code:44641-2460
Practice Address - Country:US
Practice Address - Phone:330-412-6561
Practice Address - Fax:330-875-1824
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-23
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant