Basic Information
| Provider Information | |||||||||
| NPI: | 1588022040 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GODDARD | ||||||||
| FirstName: | HEATHER | ||||||||
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| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 800 W MAGNOLIA AVE | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761044611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177597000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 920 SANTE FE DRIVE | ||||||||
| Address2: | |||||||||
| City: | WEATHERFORD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76086 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8175960637 | ||||||||
| FaxNumber: | 8175965143 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2016 | ||||||||
| LastUpdateDate: | 08/15/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | AP129779 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 3561243-01 | 05 | TX | MEDICAID |