Healthcare Provider Details

I. General information

NPI: 1699442160
Provider Name (Legal Business Name): SHAWANDA DENISE GOODMAN APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2021
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 3RD AVE S
MINNEAPOLIS MN
55401-2557
US

IV. Provider business mailing address

150 3RD AVE S
MINNEAPOLIS MN
55401-2557
US

V. Phone/Fax

Practice location:
  • Phone: 651-472-5915
  • Fax: 651-342-8443
Mailing address:
  • Phone: 651-472-5915
  • Fax: 651-342-8443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2025096570
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: