Provider Demographics
NPI:1750626552
Name:GODDARD, MARLA RENEE (RN)
Entity type:Individual
Prefix:
First Name:MARLA
Middle Name:RENEE
Last Name:GODDARD
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 KALMUS DRIVE
Mailing Address - Street 2:K3
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627
Mailing Address - Country:US
Mailing Address - Phone:714-384-3870
Mailing Address - Fax:
Practice Address - Street 1:151 KALMUS DRIVE
Practice Address - Street 2:K3
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627
Practice Address - Country:US
Practice Address - Phone:714-384-3870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-05
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA396671171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1174607626Other1174607626