Healthcare Provider Details

I. General information

NPI: 1649646183
Provider Name (Legal Business Name): THERESA GOODENOUGH FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2015
Last Update Date: 03/23/2020
Certification Date: 03/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

384 S PANTOPS DR
CHARLOTTESVILLE VA
22911-8678
US

IV. Provider business mailing address

384 S PANTOPS DR
CHARLOTTESVILLE VA
22911-8678
US

V. Phone/Fax

Practice location:
  • Phone: 607-725-0980
  • Fax:
Mailing address:
  • Phone: 607-725-0980
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License Number2005453868
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024174270
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: