Healthcare Provider Details

I. General information

NPI: 1548885874
Provider Name (Legal Business Name): SKYLAR GOODMAN POLAND AUD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2020
Last Update Date: 07/17/2025
Certification Date: 07/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 CHAMPIONS WAY
SUFFOLK VA
23435-3914
US

IV. Provider business mailing address

1030 CHAMPIONS WAY
SUFFOLK VA
23435-3914
US

V. Phone/Fax

Practice location:
  • Phone: 757-673-6118
  • Fax:
Mailing address:
  • Phone: 757-673-6118
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number2201001774
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: