Provider Demographics
NPI:1124263322
Name:GOODMAN, MARILYN D (REGISTERED NURSE)
Entity type:Individual
Prefix:
First Name:MARILYN
Middle Name:D
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:762 TOWNLINE RD
Mailing Address - Street 2:
Mailing Address - City:LYONS
Mailing Address - State:NY
Mailing Address - Zip Code:14489-9619
Mailing Address - Country:US
Mailing Address - Phone:315-331-2086
Mailing Address - Fax:
Practice Address - Street 1:848 PIERSON AVE.
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NY
Practice Address - Zip Code:14513
Practice Address - Country:US
Practice Address - Phone:315-331-2086
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-03
Last Update Date:2008-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY284222-1163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY23-7540582OtherROOSEVELT CHILDREN'S CENTER
NY1043414170OtherROOSEVELT CHILDREN'S CENTER