Provider Demographics
NPI:1467908749
Name:EZELL-GOODNER, FELICIA (APRN-CNP)
Entity Type:Individual
Prefix:MRS
First Name:FELICIA
Middle Name:
Last Name:EZELL-GOODNER
Suffix:
Gender:F
Credentials:APRN-CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 SW 89TH STREET
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73139
Mailing Address - Country:US
Mailing Address - Phone:405-632-7256
Mailing Address - Fax:
Practice Address - Street 1:1100 SW 89TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73139-9104
Practice Address - Country:US
Practice Address - Phone:405-632-7256
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-28
Last Update Date:2016-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK76100363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK05115683930Medicaid