Healthcare Provider Details

I. General information

NPI: 1013764984
Provider Name (Legal Business Name): SARA GOODWIN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SARA MASON

II. Dates (important events)

Enumeration Date: 04/30/2024
Last Update Date: 01/08/2025
Certification Date: 01/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8233 GLENCARIN BLVD
FORT WAYNE IN
46804-5784
US

IV. Provider business mailing address

11109 PARKVIEW PLAZA DR # 117
FORT WAYNE IN
46845-1701
US

V. Phone/Fax

Practice location:
  • Phone: 260-425-5470
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License Number28252299A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71015409A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: