=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063062073
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TANYA GOODEN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/12/2019
-----------------------------------------------------
Last Update Date | 09/30/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 619 19TH ST S
-----------------------------------------------------
City | BIRMINGHAM
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35249-1900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-930-7736
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4963 SULPHUR SPRINGS RD
-----------------------------------------------------
City | HOOVER
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35226-2083
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-585-4326
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 1-046051
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------