Provider Demographics
NPI:1841812260
Name:GOODNER, TERESA DIANE (FNP)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:DIANE
Last Name:GOODNER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10217 S WALNUT CANYON LN
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84009-7141
Mailing Address - Country:US
Mailing Address - Phone:801-651-8014
Mailing Address - Fax:
Practice Address - Street 1:10217 S WALNUT CANYON LN
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84009-7141
Practice Address - Country:US
Practice Address - Phone:801-651-8014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-07
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7041186-4405363LP0808X
UT7041186-3102363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily