Healthcare Provider Details

I. General information

NPI: 1841449667
Provider Name (Legal Business Name): BRANDY GOOSS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2008
Last Update Date: 12/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 WEST KANSAS
JAL NM
88252
US

IV. Provider business mailing address

327 DEEP WELLS RD
JAL NM
88252-9724
US

V. Phone/Fax

Practice location:
  • Phone: 575-395-3400
  • Fax: 575-395-2781
Mailing address:
  • Phone: 575-395-2495
  • Fax: 888-430-7095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP01280
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: