Healthcare Provider Details

I. General information

NPI: 1558074971
Provider Name (Legal Business Name): ALYSON GOODALE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2022
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 KISH HOSPITAL DR
DEKALB IL
60115-9602
US

IV. Provider business mailing address

1 KISH HOSPITAL DR
DEKALB IL
60115-9602
US

V. Phone/Fax

Practice location:
  • Phone: 815-748-2975
  • Fax: 815-981-7375
Mailing address:
  • Phone: 815-748-2975
  • Fax: 815-981-7375

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2024003085
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085012236
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: