Provider Demographics
NPI:1427822535
Name:GOEDERT, MONICA ROSE (RN)
Entity type:Individual
Prefix:MRS
First Name:MONICA
Middle Name:ROSE
Last Name:GOEDERT
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5735 SWAN LAKE DR
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-1769
Mailing Address - Country:US
Mailing Address - Phone:810-610-8494
Mailing Address - Fax:
Practice Address - Street 1:5735 SWAN LAKE DR
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-1769
Practice Address - Country:US
Practice Address - Phone:810-610-8494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-09
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704304968363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health