Provider Demographics
NPI:1831599208
Name:GOODWYN, HEATHER (CRNA)
Entity type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:
Last Name:GOODWYN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 IVY GLEN CT
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27127-4501
Mailing Address - Country:US
Mailing Address - Phone:336-601-1580
Mailing Address - Fax:
Practice Address - Street 1:1370 W D ST
Practice Address - Street 2:
Practice Address - City:NORTH WILKESBORO
Practice Address - State:NC
Practice Address - Zip Code:28659-3506
Practice Address - Country:US
Practice Address - Phone:336-651-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-03
Last Update Date:2020-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC224279367500000X
VA0024178970367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered