Provider Demographics
NPI:1528573862
Name:GOODWIN, TAWNIE (BS, RD, LD)
Entity Type:Individual
Prefix:
First Name:TAWNIE
Middle Name:
Last Name:GOODWIN
Suffix:
Gender:F
Credentials:BS, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:74245 S 320 RD
Mailing Address - Street 2:
Mailing Address - City:WAGONER
Mailing Address - State:OK
Mailing Address - Zip Code:74467-9213
Mailing Address - Country:US
Mailing Address - Phone:918-575-0485
Mailing Address - Fax:
Practice Address - Street 1:74245 S 320 RD
Practice Address - Street 2:
Practice Address - City:WAGONER
Practice Address - State:OK
Practice Address - Zip Code:74467-9213
Practice Address - Country:US
Practice Address - Phone:918-575-0485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-08
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86051388133V00000X
OK2248133V00000X
133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered