Healthcare Provider Details

I. General information

NPI: 1316774987
Provider Name (Legal Business Name): DKISHA GOODMAN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2024
Last Update Date: 09/18/2024
Certification Date: 09/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6041 SYON CV
MEMPHIS TN
38119-7429
US

IV. Provider business mailing address

3750 HACKS CROSS RD STE 102
MEMPHIS TN
38125-3206
US

V. Phone/Fax

Practice location:
  • Phone: 662-579-9850
  • Fax:
Mailing address:
  • Phone: 662-579-9850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number908059
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: