Healthcare Provider Details

I. General information

NPI: 1316379324
Provider Name (Legal Business Name): THERESA ANNE GOODMAN APRN, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: THERESA A LASELVA

II. Dates (important events)

Enumeration Date: 07/31/2013
Last Update Date: 12/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1169 EASTERN PKWY SUITE 1111
LOUISVILLE KY
40217-1417
US

IV. Provider business mailing address

1169 EASTERN PKWY SUITE 1111
LOUISVILLE KY
40217-1417
US

V. Phone/Fax

Practice location:
  • Phone: 502-456-4100
  • Fax: 502-459-8454
Mailing address:
  • Phone: 502-456-4100
  • Fax: 502-459-8454

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3007914
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1104439
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: