Provider Demographics
NPI:1245878107
Name:GODDARD, AMANDA N (BSN RN MSN FNP-BC)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:N
Last Name:GODDARD
Suffix:
Gender:F
Credentials:BSN RN MSN FNP-BC
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Other - First Name:
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Mailing Address - Street 1:3040 WILLIAMS DR STE 100
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-4618
Mailing Address - Country:US
Mailing Address - Phone:571-350-8400
Mailing Address - Fax:703-940-8697
Practice Address - Street 1:44035 RIVERSIDE PKWY STE 300
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176-8260
Practice Address - Country:US
Practice Address - Phone:703-554-6800
Practice Address - Fax:703-724-7503
Is Sole Proprietor?:No
Enumeration Date:2019-12-11
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDR205859163W00000X, 363LF0000X
VA0024178831363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1245878107Medicaid
VAVVY194AOtherMEDICARE PTAN