Provider Demographics
NPI:1346069960
Name:GOODMAN, ALICIA DORETHEA (FNP-C)
Entity type:Individual
Prefix:MRS
First Name:ALICIA
Middle Name:DORETHEA
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:ALICIA
Other - Middle Name:DORETHEA
Other - Last Name:WELLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3211 ROSEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-4517
Mailing Address - Country:US
Mailing Address - Phone:601-631-1810
Mailing Address - Fax:
Practice Address - Street 1:4300B W RAILROAD ST
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2568
Practice Address - Country:US
Practice Address - Phone:228-822-6722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-09
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS906660363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily