MEDICARE: CLARISSA ELIZABETH GOODFELLOW

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	163W00000X	Registered Nurse	KY1120070	KY
2	163W00000X	Registered Nurse	IN28195766A	IN
3	163W00000X	Registered Nurse	RN245490	OH

General Provider Information

NPI Number	:	1538757539
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CLARISSA ELIZABETH GOODFELLOW

Provider Business Mailing Address
First Line	:	3170 DICKINSON AVE
Second Line	:
City	:	CHEVIOT
State	:	OH
Zip	:	45211-2702
Country	:	US
Telephone Number	:	513-827-8499
Fax Number	:

Provider Business Practice Location Address
First Line	:	3170 DICKINSON AVE
Second Line	:
City	:	CHEVIOT
State	:	OH
Zip	:	45211-2702
Country	:	US
Telephone Number	:	513-827-8499
Fax Number	:

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

Provider Enumeration Date	:	01/05/2021
Last Update Date	:	01/05/2021

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