Provider Demographics
NPI: | 1467558833 |
---|---|
Name: | GODDARD, AMANDA LEE (RN, APRN) |
Entity Type: | Individual |
Prefix: | |
First Name: | AMANDA |
Middle Name: | LEE |
Last Name: | GODDARD |
Suffix: | |
Gender: | F |
Credentials: | RN, APRN |
Other - Prefix: | |
Other - First Name: | AMANDA |
Other - Middle Name: | LEE |
Other - Last Name: | THOMAS |
Other - Suffix: | |
Other - Last Name Type: | Former Name |
Other - Credentials: | RN, APRN |
Mailing Address - Street 1: | 5625 S 62ND ST STE 100 |
Mailing Address - Street 2: | |
Mailing Address - City: | LINCOLN |
Mailing Address - State: | NE |
Mailing Address - Zip Code: | 68516-3558 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 402-489-3834 |
Mailing Address - Fax: | 024-895-0494 |
Practice Address - Street 1: | 5625 S 62ND ST STE 100 |
Practice Address - Street 2: | |
Practice Address - City: | LINCOLN |
Practice Address - State: | NE |
Practice Address - Zip Code: | 68516-3558 |
Practice Address - Country: | US |
Practice Address - Phone: | 402-489-3834 |
Practice Address - Fax: | 402-489-5049 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-09-15 |
Last Update Date: | 2024-03-20 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NE | 110662 | 363LP0200X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363LP0200X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
NE | 10026369300 | Medicaid | |
NE | 47079049100 | Medicaid | |
NE | 10025151600 | Medicaid | |
NE | 47079049112 | Medicaid |