=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639930431
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HEATHER GOOCH RN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2024
-----------------------------------------------------
Last Update Date | 01/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1970 ROANOKE BLVD
-----------------------------------------------------
City | SALEM
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24153-6404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-210-8181
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5913 VILLAGE LN
-----------------------------------------------------
City | HOLLINS
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24019-4931
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
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 | 0024191322
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 0001328246
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------