Provider Demographics
NPI:1477945343
Name:GOODWIN, PHYLLIS (ANP)
Entity Type:Individual
Prefix:MS
First Name:PHYLLIS
Middle Name:
Last Name:GOODWIN
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16706 RIDDELL CIR
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-7600
Mailing Address - Country:US
Mailing Address - Phone:907-696-3370
Mailing Address - Fax:
Practice Address - Street 1:16706 RIDDELL CIR
Practice Address - Street 2:
Practice Address - City:EAGLE RIVER
Practice Address - State:AK
Practice Address - Zip Code:99577-7600
Practice Address - Country:US
Practice Address - Phone:907-696-3370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-02
Last Update Date:2015-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1520363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily