Healthcare Provider Details

I. General information

NPI: 1285117143
Provider Name (Legal Business Name): SEAN GODDARD MSN, APRN, PMNHP-C,
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2018
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9025 COLDWATER RD STE 100
FORT WAYNE IN
46825-2071
US

IV. Provider business mailing address

9025 COLDWATER RD STE 100
FORT WAYNE IN
46825-2071
US

V. Phone/Fax

Practice location:
  • Phone: 260-459-9225
  • Fax: 260-800-1512
Mailing address:
  • Phone: 260-459-9225
  • Fax: 260-800-1512

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number71008436A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number28206231
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number71008436A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: