=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154853950
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DIANNE GOODRIDGE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/30/2017
-----------------------------------------------------
Last Update Date | 03/30/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12381 N GRANVILLE CANYON WAY
-----------------------------------------------------
City | ORO VALLEY
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85755-6641
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-306-1855
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12381 N GRANVILLE CANYON WAY
-----------------------------------------------------
City | ORO VALLEY
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85755-6641
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-306-1855
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 1080
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------