Healthcare Provider Details

I. General information

NPI: 1609289958
Provider Name (Legal Business Name): BROOKE GOODWIN CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2014
Last Update Date: 08/22/2022
Certification Date: 08/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 SAN PABLO RD S
JACKSONVILLE FL
32224-1865
US

IV. Provider business mailing address

4500 SAN PABLO RD S
JACKSONVILLE FL
32224-1865
US

V. Phone/Fax

Practice location:
  • Phone: 904-953-2000
  • Fax:
Mailing address:
  • Phone: 904-953-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number219340
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCRNA1233
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN11019247
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: