Provider Demographics
NPI:1528086113
Name:GOODWIN, COLLEEN K (CRNP)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:K
Last Name:GOODWIN
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16125-1726
Mailing Address - Country:US
Mailing Address - Phone:724-588-9830
Mailing Address - Fax:724-588-9860
Practice Address - Street 1:110 N MAIN ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:PA
Practice Address - Zip Code:16125
Practice Address - Country:US
Practice Address - Phone:724-588-9830
Practice Address - Fax:724-588-9860
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAUP006301B363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA043225Medicare ID - Type Unspecified
PAP16841Medicare UPIN