Provider Demographics
NPI:1699442160
Name:GOODMAN, SHAWANDA DENISE (RN)
Entity type:Individual
Prefix:
First Name:SHAWANDA
Middle Name:DENISE
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1784 LACROSSE AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55119-4808
Mailing Address - Country:US
Mailing Address - Phone:651-228-3952
Mailing Address - Fax:
Practice Address - Street 1:1784 LACROSSE AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55119-4808
Practice Address - Country:US
Practice Address - Phone:612-229-9421
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-24
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2489422163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse