Provider Demographics
NPI:1609868298
Name:GOODMAN, THERESA G (NP-C)
Entity Type:Individual
Prefix:MS
First Name:THERESA
Middle Name:G
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:MS
Other - First Name:THERESA
Other - Middle Name:G
Other - Last Name:SPENCER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP-C
Mailing Address - Street 1:605 ASHTON MANOR DR
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-5330
Mailing Address - Country:US
Mailing Address - Phone:216-406-2466
Mailing Address - Fax:770-554-1621
Practice Address - Street 1:605 ASHTON MANOR DR
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-5330
Practice Address - Country:US
Practice Address - Phone:216-406-2466
Practice Address - Fax:770-554-1621
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-19
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP-06471363LF0000X
GARN152359 NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily