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General NPI Number Information
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NPI Number | 1477100857
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Entity Type | Individual
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Provider Name | LACIE ANN GOODMAN FNP-BC
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Gender | Female
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Dates
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Enumeration Date | 08/21/2019
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Last Update Date | 08/21/2019
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Provider Practice Location Address
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Address Line | 7521 COUNTRY CLUB DR APT 304
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City | LAREDO
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State | TX
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Zip | 78041-3396
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Country | US
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Telephone | 912-571-1480
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Fax |
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Provider Business Mailing Address
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Address Line | 7521 COUNTRY CLUB DR APT 304
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City | LAREDO
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State | TX
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Zip | 78041-3396
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Country | US
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Telephone | 912-571-1480
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 216526
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License Number State | GA
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