Healthcare Provider Details

I. General information

NPI: 1841812260
Provider Name (Legal Business Name): TERESA DIANE GOODNER FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2020
Last Update Date: 09/23/2024
Certification Date: 09/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10217 S WALNUT CANYON LN
SOUTH JORDAN UT
84009-7141
US

IV. Provider business mailing address

10217 S WALNUT CANYON LN
SOUTH JORDAN UT
84009-7141
US

V. Phone/Fax

Practice location:
  • Phone: 801-651-8014
  • Fax:
Mailing address:
  • Phone: 801-651-8014
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number7041186-3102
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number7041186-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: