Provider Demographics
NPI:1861263717
Name:GOODWIN, AMANDA DANIELLE (RN)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:DANIELLE
Last Name:GOODWIN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:DANIELLE
Other - Last Name:ARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:7130 W CIMMARRON DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84128-3450
Mailing Address - Country:US
Mailing Address - Phone:801-906-1988
Mailing Address - Fax:
Practice Address - Street 1:8265 W 2700 S
Practice Address - Street 2:
Practice Address - City:MAGNA
Practice Address - State:UT
Practice Address - Zip Code:84044-1323
Practice Address - Country:US
Practice Address - Phone:385-318-3200
Practice Address - Fax:801-251-1161
Is Sole Proprietor?:No
Enumeration Date:2024-01-10
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8833523-3102163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse