Provider Demographics
NPI:1609224393
Name:GOODMAN, NICOLE (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5613 OAKMEADOW DR
Mailing Address - Street 2:APT 906
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132-2469
Mailing Address - Country:US
Mailing Address - Phone:502-542-0583
Mailing Address - Fax:
Practice Address - Street 1:13172 STATE HIGHWAY 64 E
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75707-5340
Practice Address - Country:US
Practice Address - Phone:502-542-0583
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-02
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT6334390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program