Provider Demographics
NPI:1063073781
Name:GOOLSBY, ALLYSE BRITTANY
Entity type:Individual
Prefix:
First Name:ALLYSE
Middle Name:BRITTANY
Last Name:GOOLSBY
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 4466
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43610-0466
Mailing Address - Country:US
Mailing Address - Phone:419-708-1988
Mailing Address - Fax:
Practice Address - Street 1:26757 LAKEVUE DR APT 24
Practice Address - Street 2:
Practice Address - City:PERRYSBURG
Practice Address - State:OH
Practice Address - Zip Code:43551-3304
Practice Address - Country:US
Practice Address - Phone:419-708-1988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-24
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0347867Medicaid