Healthcare Provider Details

I. General information

NPI: 1073281135
Provider Name (Legal Business Name): CHANNA TERESE GOODMAN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CHANNA ROYAL RN

II. Dates (important events)

Enumeration Date: 09/02/2021
Last Update Date: 09/02/2021
Certification Date: 09/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E FERGUSON ST STE 608
TYLER TX
75702-5756
US

IV. Provider business mailing address

100 E FERGUSON ST STE 608
TYLER TX
75702-5756
US

V. Phone/Fax

Practice location:
  • Phone: 903-705-0070
  • Fax:
Mailing address:
  • Phone: 903-705-0070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number896590
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: