1538744230 NPI number — MRS. MICA RAE GOEHNER FNP

Table of content: MRS. MICA RAE GOEHNER FNP (NPI 1538744230)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538744230 NPI number — MRS. MICA RAE GOEHNER FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOEHNER
Provider First Name:
MICA
Provider Middle Name:
RAE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1538744230
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/12/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
28467 DUPONT BLVD
Provider Second Line Business Mailing Address:
UNIT 6
Provider Business Mailing Address City Name:
MILLSBORO
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19966
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
302-542-4999
Provider Business Mailing Address Fax Number:
302-448-1222

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
COASTAL CARE DERMATOLOGY, LLC
Provider Second Line Business Practice Location Address:
28467 DUPONT BLVD UNIT 6 SUSSEX PROFESSIONAL CTR
Provider Business Practice Location Address City Name:
MILLSBORO
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19966
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-542-4999
Provider Business Practice Location Address Fax Number:
302-448-1222
Provider Enumeration Date:
03/14/2021

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  LG-0011594 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: LG-001594 . This is a "DE FNP LICENSE" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".




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