Provider Demographics
NPI:1841761798
Name:GOODWIN, KELLY RAE (APRN)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:RAE
Last Name:GOODWIN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14543 LARRY ST
Mailing Address - Street 2:
Mailing Address - City:CHOCTAW
Mailing Address - State:OK
Mailing Address - Zip Code:73020-8569
Mailing Address - Country:US
Mailing Address - Phone:405-568-9165
Mailing Address - Fax:
Practice Address - Street 1:14543 LARRY ST
Practice Address - Street 2:
Practice Address - City:CHOCTAW
Practice Address - State:OK
Practice Address - Zip Code:73020-8569
Practice Address - Country:US
Practice Address - Phone:405-568-9165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-17
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAG12180060363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care