Healthcare Provider Details

I. General information

NPI: 1477254191
Provider Name (Legal Business Name): MELISSA SIMONA GOODWIN DNP, RN, PMHNP-BC,
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2023
Last Update Date: 03/10/2023
Certification Date: 03/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 EMANCIPATION DR
HAMPTON VA
23667-0001
US

IV. Provider business mailing address

13087 SMITHS NECK RD
CARROLLTON VA
23314-3613
US

V. Phone/Fax

Practice location:
  • Phone: 757-722-9961
  • Fax:
Mailing address:
  • Phone: 757-593-1987
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number0024186707
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: