Healthcare Provider Details

I. General information

NPI: 1912416124
Provider Name (Legal Business Name): SUSAN JOY GOODEMOTE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2017
Last Update Date: 01/16/2024
Certification Date: 01/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 8TH ST N
MOUNTAIN LAKE MN
56159-1568
US

IV. Provider business mailing address

PO BOX 5074
SIOUX FALLS SD
57117-5074
US

V. Phone/Fax

Practice location:
  • Phone: 507-427-3332
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number173042
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3929
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: