Provider Demographics
NPI:1033773981
Name:GOODNER, AMY
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:GOODNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 NW 49TH ST STE 125
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33309-3750
Mailing Address - Country:US
Mailing Address - Phone:954-527-6041
Mailing Address - Fax:
Practice Address - Street 1:1101 W BROWARD BLVD
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33312-1638
Practice Address - Country:US
Practice Address - Phone:954-527-6041
Practice Address - Fax:954-527-6052
Is Sole Proprietor?:No
Enumeration Date:2019-04-25
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLU06719207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program