Healthcare Provider Details

I. General information

NPI: 1609737303
Provider Name (Legal Business Name): KATELYN GOODYEAR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2025
Last Update Date: 11/25/2025
Certification Date: 11/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1183 MONROE AVE
ROCHESTER NY
14620-1699
US

IV. Provider business mailing address

1183 MONROE AVE
ROCHESTER NY
14620-1699
US

V. Phone/Fax

Practice location:
  • Phone: 716-792-9991
  • Fax:
Mailing address:
  • Phone: 716-792-9991
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number801523
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: