Healthcare Provider Details

I. General information

NPI: 1992596035
Provider Name (Legal Business Name): BRANDY AMBERLYN GOODWIN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2025
Last Update Date: 05/16/2025
Certification Date: 05/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10159 E 11TH ST
TULSA OK
74128-3058
US

IV. Provider business mailing address

10159 E 11TH ST
TULSA OK
74128-3058
US

V. Phone/Fax

Practice location:
  • Phone: 918-686-3246
  • Fax:
Mailing address:
  • Phone: 918-686-3246
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License NumberR0110609
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: