Provider Demographics
NPI:1154143089
Name:GOODWATER, MIKAELA R (FNP-C)
Entity type:Individual
Prefix:
First Name:MIKAELA
Middle Name:R
Last Name:GOODWATER
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:MIKAELA
Other - Middle Name:R
Other - Last Name:CARLOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:715 S 9TH ST
Mailing Address - Street 2:
Mailing Address - City:CANON CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81212-4911
Mailing Address - Country:US
Mailing Address - Phone:719-269-8820
Mailing Address - Fax:
Practice Address - Street 1:715 S 9TH ST
Practice Address - Street 2:
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-4911
Practice Address - Country:US
Practice Address - Phone:719-269-8820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-30
Last Update Date:2025-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN.1000278-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily