Provider Demographics
NPI:1265169676
Name:GOODMAN, TIFFANY MARIE (AGPCNP-BC)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:MARIE
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:AGPCNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10730 HUNTER LAKE LN
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46239-8986
Mailing Address - Country:US
Mailing Address - Phone:317-531-1783
Mailing Address - Fax:
Practice Address - Street 1:10730 HUNTER LAKE LN
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46239-8986
Practice Address - Country:US
Practice Address - Phone:317-531-1783
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-05
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN2022030116363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care