Provider Demographics
NPI:1164740510
Name:GOODWIN, DARA NICOLE
Entity Type:Individual
Prefix:
First Name:DARA
Middle Name:NICOLE
Last Name:GOODWIN
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 1:543 JONESBORO RD
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-3718
Mailing Address - Country:US
Mailing Address - Phone:678-583-9071
Mailing Address - Fax:
Practice Address - Street 1:543 JONESBORO RD
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-3718
Practice Address - Country:US
Practice Address - Phone:678-583-9071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-10
Last Update Date:2010-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN180693363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics