Provider Demographics
NPI:1063256519
Name:GOODMAN-TAYLOR, SHANICE CARNELLA
Entity type:Individual
Prefix:
First Name:SHANICE
Middle Name:CARNELLA
Last Name:GOODMAN-TAYLOR
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 1:42941 NORTHVILLE PLACE DR APT 1612
Mailing Address - Street 2:
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48167-2924
Mailing Address - Country:US
Mailing Address - Phone:313-598-9187
Mailing Address - Fax:
Practice Address - Street 1:6800 W MAPLE RD
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-2792
Practice Address - Country:US
Practice Address - Phone:248-788-5300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-20
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703128440164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse