Healthcare Provider Details

I. General information

NPI: 1780829325
Provider Name (Legal Business Name): MICHELE M. GOODWIN CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2008
Last Update Date: 04/25/2024
Certification Date: 04/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34TH ST AND CIVIC CENTER BLVD
PHILADELPHIA PA
19104-4399
US

IV. Provider business mailing address

131 OAK GLEN RD
TOMS RIVER NJ
08753-3478
US

V. Phone/Fax

Practice location:
  • Phone: 215-590-1000
  • Fax:
Mailing address:
  • Phone: 732-573-0151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0222X
TaxonomyCritical Care Pediatric Nurse Practitioner
License NumberSP010074
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363LP0222X
TaxonomyCritical Care Pediatric Nurse Practitioner
License Number26NJ01250500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: