Healthcare Provider Details

I. General information

NPI: 1821010927
Provider Name (Legal Business Name): JUANITA I. GOODEN-JOHNSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1524 MCHENRY AVE.
MODESTO CA
95350-4500
US

IV. Provider business mailing address

1524 MCHENRY AVE
MODESTO CA
95350-4500
US

V. Phone/Fax

Practice location:
  • Phone: 209-557-6200
  • Fax: 209-557-6239
Mailing address:
  • Phone: 209-557-6200
  • Fax: 209-557-6239

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number479300
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: