Healthcare Provider Details

I. General information

NPI: 1679331219
Provider Name (Legal Business Name): MRS. BRENDA LEE GOODNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2024
Last Update Date: 03/07/2025
Certification Date: 03/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

802 KENYON RD
FORT DODGE IA
50501-5740
US

IV. Provider business mailing address

8921 TWIN LAKES RD
MANSON IA
50563-7012
US

V. Phone/Fax

Practice location:
  • Phone: 515-573-3101
  • Fax:
Mailing address:
  • Phone: 515-570-0859
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number125895
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberA179734
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: