Provider Demographics
NPI:1669079976
Name:GOOD, MARY LYNN (PMHNP)
Entity type:Individual
Prefix:
First Name:MARY LYNN
Middle Name:
Last Name:GOOD
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3344 CHAMBERS RD # 200
Mailing Address - Street 2:
Mailing Address - City:HORSEHEADS
Mailing Address - State:NY
Mailing Address - Zip Code:14845-1403
Mailing Address - Country:US
Mailing Address - Phone:607-734-2264
Mailing Address - Fax:
Practice Address - Street 1:3344 CHAMBERS RD # 200
Practice Address - Street 2:
Practice Address - City:HORSEHEADS
Practice Address - State:NY
Practice Address - Zip Code:14845-1403
Practice Address - Country:US
Practice Address - Phone:607-734-2264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-08
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF403093-01363LP0808X
NY403093363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health