=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053931352
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | IYISHA GODFREY RN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/16/2020
-----------------------------------------------------
Last Update Date | 07/28/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 324 E 244TH ST
-----------------------------------------------------
City | EUCLID
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44123-1435
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-801-3521
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 435 E MAIN ST APT 440
-----------------------------------------------------
City | MESA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85203-2205
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-801-3521
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WH0500X
-----------------------------------------------------
Taxonomy Name | Hemodialysis Registered Nurse
-----------------------------------------------------
License Number | RN.413761
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------