Healthcare Provider Details

I. General information

NPI: 1861893414
Provider Name (Legal Business Name): BENJAMIN ASHBY GOODRUM CNM, FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2014
Last Update Date: 05/06/2025
Certification Date: 05/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2450 ASHBY AVE
BERKELEY CA
94705-2067
US

IV. Provider business mailing address

PO BOX 276950
SACRAMENTO CA
95827-6950
US

V. Phone/Fax

Practice location:
  • Phone: 510-204-3977
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number201406326NP-PP
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberF002184-01
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberCNM236316
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: