Healthcare Provider Details

I. General information

NPI: 1053931352
Provider Name (Legal Business Name): IYISHA GODFREY RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2020
Last Update Date: 07/28/2023
Certification Date: 07/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

324 E 244TH ST
EUCLID OH
44123-1435
US

IV. Provider business mailing address

435 E MAIN ST APT 440
MESA AZ
85203-2205
US

V. Phone/Fax

Practice location:
  • Phone: 216-801-3521
  • Fax:
Mailing address:
  • Phone: 216-801-3521
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0500X
TaxonomyHemodialysis Registered Nurse
License NumberRN.413761
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: