Basic Information
| Provider Information | |||||||||
| NPI: | 1851973382 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOODWIN | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | ELISE | ||||||||
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| Credential: | FNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1521 N PINE CLIFF DR | ||||||||
| Address2: | |||||||||
| City: | FLAGSTAFF | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860013269 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9284402350 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1521 N PINE CLIFF DR | ||||||||
| Address2: | |||||||||
| City: | FLAGSTAFF | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860013269 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9284402350 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2021 | ||||||||
| LastUpdateDate: | 04/23/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP2300X | 250702 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
No ID Information.