Healthcare Provider Details

I. General information

NPI: 1124667084
Provider Name (Legal Business Name): KATHLEEN GOODEN GOODEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/24/2019
Last Update Date: 12/24/2019
Certification Date: 12/24/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 N LIGHTNING A DR
TUCSON AZ
85749-7922
US

IV. Provider business mailing address

2501 N LIGHTNING A DR
TUCSON AZ
85749-7922
US

V. Phone/Fax

Practice location:
  • Phone: 520-404-5105
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: