Basic Information
| Provider Information | |||||||||
| NPI: | 1750790754 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOFF | ||||||||
| FirstName: | DEDRA | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | FNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6626 E 75TH ST STE 500 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462502890 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3176217561 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9669 E 146TH ST STE 250 | ||||||||
| Address2: | |||||||||
| City: | NOBLESVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460605006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3176215719 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2014 | ||||||||
| LastUpdateDate: | 06/18/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 2014014914 | WV | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | COA.16884-NP | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 71008322A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 0109921 | 05 | OH | MEDICAID | 3810027996 | 05 | WV | MEDICAID | P01529305 | 01 | OH | RAILROAD MEDICARE | OTHER |