Provider Demographics
NPI:1316278971
Name:GODWIN, ABBY NICOLE (CRNA)
Entity type:Individual
Prefix:MRS
First Name:ABBY
Middle Name:NICOLE
Last Name:GODWIN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 S BECKHAM AVE
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-1908
Mailing Address - Country:US
Mailing Address - Phone:903-531-8638
Mailing Address - Fax:817-877-0350
Practice Address - Street 1:1000 S BECKHAM AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-1908
Practice Address - Country:US
Practice Address - Phone:903-531-8638
Practice Address - Fax:817-877-0350
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-21
Last Update Date:2010-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX083721367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered