Provider Demographics
NPI:1295786713
Name:GOODMAN, BRENDA FAYE (FNP)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:FAYE
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16740 DAVIDSON CONCORD RD
Practice Address - Street 2:STE 200
Practice Address - City:DAVIDSON
Practice Address - State:NC
Practice Address - Zip Code:28036-8746
Practice Address - Country:US
Practice Address - Phone:704-444-5881
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5006998363L00000X, 363LP0808X, 363LF0000X
NC267100363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1295786713Medicaid
WV9600239000Medicaid
VA007794525Medicaid
SCQNP273Medicaid
NC1295786713Medicaid
S99076Medicare UPIN
VA007794525Medicaid
WV9600239000Medicaid
WV2034691Medicare PIN
00V684F84Medicare PIN