Basic Information
| Provider Information | |||||||||
| NPI: | 1952875122 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOODWIN | ||||||||
| FirstName: | TESSAMY | ||||||||
| MiddleName: | LYNNE | ||||||||
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| Credential: | NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 276 SUTTON RD | ||||||||
| Address2: | |||||||||
| City: | TIFTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317942221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2293922502 | ||||||||
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| Practice Location | |||||||||
| Address1: | 39 KENT RD STE 2 | ||||||||
| Address2: | |||||||||
| City: | TIFTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317941697 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2293889393 | ||||||||
| FaxNumber: | 2293889855 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/21/2019 | ||||||||
| LastUpdateDate: | 03/24/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | RN118359 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.