Healthcare Provider Details

I. General information

NPI: 1043083678
Provider Name (Legal Business Name): MICAH GOODWIN APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2023
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 OLYMPIC PL
TOWSON MD
21204-4104
US

IV. Provider business mailing address

1 OLYMPIC PL
TOWSON MD
21204-4104
US

V. Phone/Fax

Practice location:
  • Phone: 888-444-1378
  • Fax: 410-584-5440
Mailing address:
  • Phone: 888-444-1374
  • Fax: 410-584-5440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR244861
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: