Healthcare Provider Details

I. General information

NPI: 1225303282
Provider Name (Legal Business Name): KATANYA KATRINA GOSWELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2012
Last Update Date: 01/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1330 E COOLEY DR
COLTON CA
92324-3905
US

IV. Provider business mailing address

1950 S SUNWEST LN SUITE 200
SAN BERNARDINO CA
92408-3258
US

V. Phone/Fax

Practice location:
  • Phone: 909-423-0750
  • Fax: 909-423-0760
Mailing address:
  • Phone: 800-722-9886
  • Fax: 909-252-4055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: