Provider Demographics
NPI:1881301919
Name:GOOMBI, EDWINA
Entity type:Individual
Prefix:
First Name:EDWINA
Middle Name:
Last Name:GOOMBI
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 1:514 EAST GRACEMONT ST
Mailing Address - Street 2:
Mailing Address - City:GRACEMONT
Mailing Address - State:OK
Mailing Address - Zip Code:73042
Mailing Address - Country:US
Mailing Address - Phone:405-648-2291
Mailing Address - Fax:
Practice Address - Street 1:804 W CHOCTAW AVE
Practice Address - Street 2:
Practice Address - City:CHICKASHA
Practice Address - State:OK
Practice Address - Zip Code:73018-2310
Practice Address - Country:US
Practice Address - Phone:405-424-7711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-28
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator