Provider Demographics
NPI:1497208250
Name:GOODWIN, BERONICA
Entity Type:Individual
Prefix:
First Name:BERONICA
Middle Name:
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 1:937 SEWELL RD
Mailing Address - Street 2:
Mailing Address - City:TRINITY
Mailing Address - State:AL
Mailing Address - Zip Code:35673-6625
Mailing Address - Country:US
Mailing Address - Phone:256-345-9753
Mailing Address - Fax:
Practice Address - Street 1:1102B SUITE #2 4TH AVE SE
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:AL
Practice Address - Zip Code:35601
Practice Address - Country:US
Practice Address - Phone:356-822-1300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-28
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL16395374U00000X
AL2-055526164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No374U00000XNursing Service Related ProvidersHome Health Aide