Basic Information
| Provider Information | |||||||||
| NPI: | 1952383812 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOODIN | ||||||||
| FirstName: | SONYA | ||||||||
| MiddleName: | K. | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1171 HART ST | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 390464805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018599888 | ||||||||
| FaxNumber: | 6018599004 | ||||||||
| Practice Location | |||||||||
| Address1: | 1082 GLUCKSTADT RD | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6017075621 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2005 | ||||||||
| LastUpdateDate: | 05/06/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | R850539 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | P00218140 | 01 | RAILROAD MEDICARE | OTHER | 09289510 | 05 | MS | MEDICAID |