Healthcare Provider Details

I. General information

NPI: 1952776890
Provider Name (Legal Business Name): AMY LEE GOEDECKE RN,MSN,FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/03/2015
Last Update Date: 12/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 E MAIN ST
WHITESBORO TX
76273-1805
US

IV. Provider business mailing address

401 E MAIN ST
WHITESBORO TX
76273-1805
US

V. Phone/Fax

Practice location:
  • Phone: 903-564-7709
  • Fax: 903-564-7090
Mailing address:
  • Phone: 903-564-7709
  • Fax: 903-564-7090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP129412
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number87252
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: