Provider Demographics
NPI:1053557645
Name:GOODALL, HEATHER A (APRN)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:A
Last Name:GOODALL
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:975 HOPKINSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42276-9774
Mailing Address - Country:US
Mailing Address - Phone:270-726-9568
Mailing Address - Fax:270-726-9570
Practice Address - Street 1:975 HOPKINSVILLE RD
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:KY
Practice Address - Zip Code:42276-9774
Practice Address - Country:US
Practice Address - Phone:270-726-9568
Practice Address - Fax:270-726-9570
Is Sole Proprietor?:No
Enumeration Date:2009-01-02
Last Update Date:2014-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3005661363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYP01000559OtherRAILROAD MEDICARE
KY7100099720Medicaid
KY000000698117OtherANTHEM BCBS
KYP01000559OtherRAILROAD MEDICARE