Healthcare Provider Details

I. General information

NPI: 1144053034
Provider Name (Legal Business Name): MCKENNA BAYLEE GOODMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2024
Last Update Date: 08/26/2024
Certification Date: 08/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 JOHN MARSHALL DR HUNTINGTON WV 25755 KH145
HUNTINGTON WV
25755-0001
US

IV. Provider business mailing address

67 MAYFAIR WAY
HUNTINGTON WV
25705-3836
US

V. Phone/Fax

Practice location:
  • Phone: 304-696-7302
  • Fax:
Mailing address:
  • Phone: 304-638-8994
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberIN0010522
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: