Provider Demographics
NPI:1053528356
Name:GOODRICH, SONYA L (NP)
Entity type:Individual
Prefix:
First Name:SONYA
Middle Name:L
Last Name:GOODRICH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 CLINTON AVE
Mailing Address - Street 2:SUITE 140
Mailing Address - City:IRVINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07111-2070
Mailing Address - Country:US
Mailing Address - Phone:973-374-1080
Mailing Address - Fax:973-373-1726
Practice Address - Street 1:1200 CLINTON AVE
Practice Address - Street 2:SUITE 140
Practice Address - City:IRVINGTON
Practice Address - State:NJ
Practice Address - Zip Code:07111-2070
Practice Address - Country:US
Practice Address - Phone:973-374-1080
Practice Address - Fax:973-373-1726
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NN09682500363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0500330Medicaid