Provider Demographics
NPI:1760946412
Name:GOODWYN, SIMONE
Entity Type:Individual
Prefix:
First Name:SIMONE
Middle Name:
Last Name:GOODWYN
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:PO BOX 541
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23439-0541
Mailing Address - Country:US
Mailing Address - Phone:252-267-9746
Mailing Address - Fax:
Practice Address - Street 1:652 CAROLINA RD
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-4870
Practice Address - Country:US
Practice Address - Phone:252-267-9746
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-28
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle