Healthcare Provider Details

I. General information

NPI: 1023099637
Provider Name (Legal Business Name): JULIAN GOOD FNP, PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2005
Last Update Date: 11/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 W 29TH ST
CHEYENNE WY
82001-2760
US

IV. Provider business mailing address

510 W 29TH ST
CHEYENNE WY
82001-2760
US

V. Phone/Fax

Practice location:
  • Phone: 330-763-2936
  • Fax: 307-637-6852
Mailing address:
  • Phone: 330-763-2936
  • Fax: 307-637-6852

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number19109.0857
License Number StateWY
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number19109.0857
License Number StateWY
# 3
Primary TaxonomyN
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License Number19109.0857
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: