Healthcare Provider Details

I. General information

NPI: 1437445988
Provider Name (Legal Business Name): MISS NELSON RENEE GOODWIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2011
Last Update Date: 06/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4160 S PECOS RD STE 17
LAS VEGAS NV
89121-5027
US

IV. Provider business mailing address

4160 S. PECOS SUITE 17
LAS VEGAS NV
89121
US

V. Phone/Fax

Practice location:
  • Phone: 702-332-8777
  • Fax:
Mailing address:
  • Phone: 702-332-8777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: