Healthcare Provider Details

I. General information

NPI: 1801244397
Provider Name (Legal Business Name): MARIETTA GOODLIFF APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2016
Last Update Date: 12/29/2022
Certification Date: 12/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1211 JACARANDA BLVD UNIT 2
VENICE FL
34292-4520
US

IV. Provider business mailing address

PO BOX 25487
SARASOTA FL
34277-2487
US

V. Phone/Fax

Practice location:
  • Phone: 941-483-3377
  • Fax: 941-483-4687
Mailing address:
  • Phone: 941-202-5342
  • Fax: 855-253-4836

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number340601
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: