Healthcare Provider Details

I. General information

NPI: 1578569133
Provider Name (Legal Business Name): DEIDRE VIAN GOLDSMITH C.R.N.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2005
Last Update Date: 09/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5401 OLD COURT RD
RANDALLSTOWN MD
21133-5103
US

IV. Provider business mailing address

10 SHIRECREST
AVON CT
06001-3965
US

V. Phone/Fax

Practice location:
  • Phone: 410-521-2200
  • Fax:
Mailing address:
  • Phone: 443-831-0093
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR141638
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: