Provider Demographics
NPI:1225886856
Name:GOODALL, CANANDRA
Entity type:Individual
Prefix:
First Name:CANANDRA
Middle Name:
Last Name:GOODALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9165 OTIS AVE STE 229
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46216-2321
Mailing Address - Country:US
Mailing Address - Phone:317-455-6744
Mailing Address - Fax:
Practice Address - Street 1:9165 OTIS AVE STE 229
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46216-2321
Practice Address - Country:US
Practice Address - Phone:317-455-6744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-08
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN3747A0650X
IN23016345-13747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider