Healthcare Provider Details

I. General information

NPI: 1457696957
Provider Name (Legal Business Name): STACEY LYNN GOBEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2012
Last Update Date: 12/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3852 HAMMOND AVE
WATERLOO IA
50702-5618
US

IV. Provider business mailing address

131 ENTERPRISE RD
JOHNSTOWN NY
12095-3326
US

V. Phone/Fax

Practice location:
  • Phone: 319-235-4358
  • Fax: 319-235-8061
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number000964
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: