Provider Demographics
NPI:1043083678
Name:GOODWIN, MICAH VERONICA (RN)
Entity Type:Individual
Prefix:
First Name:MICAH
Middle Name:VERONICA
Last Name:GOODWIN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3704 MARRIOTTSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:RANDALLSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21133-2402
Mailing Address - Country:US
Mailing Address - Phone:443-977-2066
Mailing Address - Fax:
Practice Address - Street 1:3704 MARRIOTTSVILLE RD
Practice Address - Street 2:
Practice Address - City:RANDALLSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21133-2402
Practice Address - Country:US
Practice Address - Phone:443-977-2066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-06
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR244861163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse