Provider Demographics
NPI:1679265730
Name:GOODEN, JUSTINE LOUISE (AGNP-C)
Entity Type:Individual
Prefix:
First Name:JUSTINE
Middle Name:LOUISE
Last Name:GOODEN
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13122 FRANCIS LEWIS BLVD
Mailing Address - Street 2:
Mailing Address - City:LAURELTON
Mailing Address - State:NY
Mailing Address - Zip Code:11413-1843
Mailing Address - Country:US
Mailing Address - Phone:347-822-3770
Mailing Address - Fax:
Practice Address - Street 1:161 FT WASHINGTN AVE STE 862
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3729
Practice Address - Country:US
Practice Address - Phone:212-305-1909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-25
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY730504-01163WP2201X
NYF310887-01363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care