=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053528356
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SONYA L GOODRICH NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/17/2007
-----------------------------------------------------
Last Update Date | 04/05/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1200 CLINTON AVE SUITE 140
-----------------------------------------------------
City | IRVINGTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07111-2070
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-374-1080
-----------------------------------------------------
Fax | 973-373-1726
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1200 CLINTON AVE SUITE 140
-----------------------------------------------------
City | IRVINGTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07111-2070
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-374-1080
-----------------------------------------------------
Fax | 973-373-1726
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | 26NN09682500
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------