MEDICARE: KATIE JO GOODALL

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	117177	IA

General Provider Information

NPI Number	:	1730058025
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATIE JO GOODALL

Provider Business Mailing Address
First Line	:	16633 DELLWOOD DR
Second Line	:
City	:	CLIVE
State	:	IA
Zip	:	50325-2590
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2304 UNIVERSITY AVE
Second Line	:
City	:	DES MOINES
State	:	IA
Zip	:	50311-4316
Country	:	US
Telephone Number	:	877-859-0542
Fax Number	:

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

Provider Enumeration Date	:	11/04/2025
Last Update Date	:	11/04/2025

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