Healthcare Provider Details

I. General information

NPI: 1639396914
Provider Name (Legal Business Name): KELLY A GOODMAN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 07/14/2025
Certification Date: 07/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4701 SANGAMORE ROAD SUITE 5207
BETHESDA MD
20816-2529
US

IV. Provider business mailing address

4701 SANGAMORE ROAD SUITE 5207
BETHESDA MD
20816-2529
US

V. Phone/Fax

Practice location:
  • Phone: 202-684-7167
  • Fax: 240-483-0441
Mailing address:
  • Phone: 202-684-7167
  • Fax: 240-483-0441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberRN966360
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License NumberR156558
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberR156558
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: