Provider Demographics
NPI:1124330139
Name:GOODNO, AMANDA LYNN (MD)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:LYNN
Last Name:GOODNO
Suffix:
Gender:F
Credentials:MD
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 3788
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29230-3788
Mailing Address - Country:US
Mailing Address - Phone:803-733-5969
Mailing Address - Fax:803-217-0026
Practice Address - Street 1:500 N 12TH ST
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-6502
Practice Address - Country:US
Practice Address - Phone:803-217-0415
Practice Address - Fax:803-939-1650
Is Sole Proprietor?:No
Enumeration Date:2010-07-07
Last Update Date:2013-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC32741208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC327417Medicaid
SC327417Medicaid