Provider Demographics
NPI:1730699208
Name:GOODEN, NICHELLE
Entity type:Individual
Prefix:
First Name:NICHELLE
Middle Name:
Last Name:GOODEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 381
Mailing Address - Street 2:
Mailing Address - City:PINE LAKE
Mailing Address - State:GA
Mailing Address - Zip Code:30072-0381
Mailing Address - Country:US
Mailing Address - Phone:404-996-9335
Mailing Address - Fax:
Practice Address - Street 1:1408 COLONY EAST CIR
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30083-5407
Practice Address - Country:US
Practice Address - Phone:404-996-9335
Practice Address - Fax:404-996-9335
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-10
Last Update Date:2017-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA058242336172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver