MEDICARE: SHAWANDA DENISE GOODMAN APRN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	2025096570	MN

General Provider Information

NPI Number	:	1699442160
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHAWANDA DENISE GOODMAN APRN

Provider Business Mailing Address
First Line	:	4180 THIELMAN LN STE 100
Second Line	:
City	:	SAINT CLOUD
State	:	MN
Zip	:	56301-4692
Country	:	US
Telephone Number	:	612-229-9421
Fax Number	:

Provider Business Practice Location Address
First Line	:	4180 THIELMAN LN STE 100
Second Line	:
City	:	SAINT CLOUD
State	:	MN
Zip	:	56301-4692
Country	:	US
Telephone Number	:	320-281-3154
Fax Number	:	833-973-4798

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/24/2021
Last Update Date	:	03/10/2026

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