Basic Information
| Provider Information | |||||||||
| NPI: | 1285698308 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOODWINE | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | NICOLE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | AU.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3986 FETTLER PARK DR | ||||||||
| Address2: | |||||||||
| City: | DUMFRIES | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220251997 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7032218307 | ||||||||
| FaxNumber: | 7032218548 | ||||||||
| Practice Location | |||||||||
| Address1: | 3986 FETTLER PARK DR | ||||||||
| Address2: | |||||||||
| City: | DUMFRIES | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220251997 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7032218307 | ||||||||
| FaxNumber: | 7032218548 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2006 | ||||||||
| LastUpdateDate: | 11/02/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | 2201000658 | VA | Y | Speech, Language and Hearing Service Providers | Audiologist | 237600000X | 2101001172 | VA | N | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter |
ID Information
| ID | Type | State | Issuer | Description | 010244919 | 05 | VA | MEDICAID | 392788YGFF | 01 | VA | MEDICARE | OTHER |