Provider Demographics
NPI:1851973382
Name:GOODWIN, NICOLE ELISE (FNP-BC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ELISE
Last Name:GOODWIN
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1521 N PINE CLIFF DR
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-3269
Mailing Address - Country:US
Mailing Address - Phone:928-440-2350
Mailing Address - Fax:
Practice Address - Street 1:2187 N VICKEY ST
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004-6121
Practice Address - Country:US
Practice Address - Phone:928-527-1899
Practice Address - Fax:928-447-5141
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-23
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ250702363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care