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
StateLicense IDTaxonomies
NE110662363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10026369300Medicaid
NE47079049100Medicaid
NE10025151600Medicaid
NE47079049112Medicaid