Provider Demographics
NPI:1497321723
Name:GOODHART, ALICIA NICOLE
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:NICOLE
Last Name:GOODHART
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 1:898 CORNETT BRANCH RD
Mailing Address - Street 2:
Mailing Address - City:LAKE OZARK
Mailing Address - State:MO
Mailing Address - Zip Code:65049-9356
Mailing Address - Country:US
Mailing Address - Phone:573-434-1276
Mailing Address - Fax:
Practice Address - Street 1:1870 BAGNELL DAM BLVD
Practice Address - Street 2:
Practice Address - City:LAKE OZARK
Practice Address - State:MO
Practice Address - Zip Code:65049-8658
Practice Address - Country:US
Practice Address - Phone:573-365-2318
Practice Address - Fax:573-365-3009
Is Sole Proprietor?:No
Enumeration Date:2021-05-27
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021012241363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily