Healthcare Provider Details

I. General information

NPI: 1285698308
Provider Name (Legal Business Name): AMY NICOLE GOODWINE AU.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2006
Last Update Date: 11/02/2022
Certification Date: 11/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3986 FETTLER PARK DR
DUMFRIES VA
22025-1997
US

IV. Provider business mailing address

3986 FETTLER PARK DR
DUMFRIES VA
22025-1997
US

V. Phone/Fax

Practice location:
  • Phone: 703-221-8307
  • Fax: 703-221-8548
Mailing address:
  • Phone: 703-221-8307
  • Fax: 703-221-8548

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number2201000658
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number2101001172
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: