Healthcare Provider Details

I. General information

NPI: 1194874016
Provider Name (Legal Business Name): ELIZABETH SHELLY GOODIEL C.R.N.F.A,M.S.N.,CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 10/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3650 JOSEPH SIEWICK DR SUITE 203
FAIRFAX VA
22033-1710
US

IV. Provider business mailing address

2028 OPITZ BLVD SUITE ONE
WOODBRIDGE VA
22191-3306
US

V. Phone/Fax

Practice location:
  • Phone: 703-391-1500
  • Fax: 703-860-1549
Mailing address:
  • Phone: 703-690-2295
  • Fax: 703-690-6445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number0001074325
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number0024074325
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number0001074325
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: