Healthcare Provider Details

I. General information

NPI: 1689061855
Provider Name (Legal Business Name): AUNDREA GOODEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2015
Last Update Date: 07/18/2023
Certification Date: 07/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3302 VOLLMER RD
OLYMPIA FIELDS IL
60461-1179
US

IV. Provider business mailing address

321 FRIAR TUCK DR
SCHERERVILLE IN
46375-1811
US

V. Phone/Fax

Practice location:
  • Phone: 708-898-0811
  • Fax:
Mailing address:
  • Phone: 773-354-9371
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number277001961
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.012421
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: