Provider Demographics
NPI:1447290093
Name:GOODEYON, ADELE HAMETT (NP)
Entity type:Individual
Prefix:
First Name:ADELE
Middle Name:HAMETT
Last Name:GOODEYON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:ADELE
Other - Middle Name:H
Other - Last Name:MAFOZA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1540 FLORIDA AVE
Mailing Address - Street 2:#100
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-4430
Mailing Address - Country:US
Mailing Address - Phone:209-577-5557
Mailing Address - Fax:209-577-8125
Practice Address - Street 1:1540 FLORIDA AVE
Practice Address - Street 2:#100
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4430
Practice Address - Country:US
Practice Address - Phone:209-577-5557
Practice Address - Fax:209-577-8125
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA277219NP7249363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ76734ZMedicaid
CAZZZ76734ZMedicare ID - Type Unspecified