Doctor Name: | LISA GODDARD |
NPI Number: | 1255617783 |
Entity Type Code: | Individual (1) |
Gender: | F |
Credentials: | CPNP |
License Number: | 4704198684 |
Business Practice Address: | 105 Commerce Dr Brockway, MI - 480973460 |
Business Phone Number: | 8103879612 |
Business Fax Number: | 8103879611 |
Mailing Address: | 3050 Commerce Dr, Suite B FORT GRATIOT |
State: | MI |
Postal Code: | 480593819 |
Phone Number: | 8103854441 |
Fax Number: | 8103851540 |
NPI Enumeration Date: | 10/28/2011 |
NPI Last Update Date: | 10/28/2011 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 363LP0200X |
License Number: | 4704198684 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | MI |
Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
Taxonomy Classification: | Nurse Practitioner |
Taxonomy Specialization: | Pediatrics |
Taxonomy Definition: |