MEDICARE: KATRYNA GOODMAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171W00000X	Contractor	009436	GA

General Provider Information

NPI Number	:	1417282492
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATRYNA GOODMAN

Provider Business Mailing Address
First Line	:	19111 PARK PLACE BLVD
Second Line	:
City	:	EUSTIS
State	:	FL
Zip	:	32736-7262
Country	:	US
Telephone Number	:	513-814-6708
Fax Number	:

Provider Business Practice Location Address
First Line	:	19111 PARK PLACE BLVD
Second Line	:
City	:	EUSTIS
State	:	FL
Zip	:	32736-7262
Country	:	US
Telephone Number	:	317-388-0800
Fax Number	:	317-388-0805

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/09/2009
Last Update Date	:	09/04/2024

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Directions to “ KATRYNA GOODMAN ” Practice Location

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