Provider Demographics
NPI:1952869166
Name:GOODSON, WANAKI (RN)
Entity Type:Individual
Prefix:
First Name:WANAKI
Middle Name:
Last Name:GOODSON
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 1:34886 PENNINGTON DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48335-2043
Mailing Address - Country:US
Mailing Address - Phone:248-981-8639
Mailing Address - Fax:
Practice Address - Street 1:182 BONDIE ST
Practice Address - Street 2:
Practice Address - City:WYANDOTTE
Practice Address - State:MI
Practice Address - Zip Code:48192-2718
Practice Address - Country:US
Practice Address - Phone:248-981-8639
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-06
Last Update Date:2022-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703107560164W00000X
MI4704364279163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
No164W00000XNursing Service ProvidersLicensed Practical Nurse