Healthcare Provider Details

I. General information

NPI: 1609712629
Provider Name (Legal Business Name): STEPHANIE MARVA GOODEN APRN-FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2026
Last Update Date: 04/24/2026
Certification Date: 04/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

94 MIDIAN AVE
WINDSOR CT
06095-4221
US

IV. Provider business mailing address

94 MIDIAN AVE
WINDSOR CT
06095-4221
US

V. Phone/Fax

Practice location:
  • Phone: 860-920-8320
  • Fax:
Mailing address:
  • Phone: 860-920-8320
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number17236
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: