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: 03/10/2026
Certification Date: 03/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4180 THIELMAN LN STE 100
SAINT CLOUD MN
56301-4692
US

IV. Provider business mailing address

4180 THIELMAN LN STE 100
SAINT CLOUD MN
56301-4692
US

V. Phone/Fax

Practice location:
  • Phone: 320-281-3154
  • Fax: 833-973-4798
Mailing address:
  • Phone: 612-229-9421
  • Fax:

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: