Healthcare Provider Details

I. General information

NPI: 1255397907
Provider Name (Legal Business Name): DIANE M GOODMAN NP APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1445 N HUNT CLUB ROAD SUITE 102
GURNEE IL
60031
US

IV. Provider business mailing address

9217 73RD ST
KENOSHA WI
53142
US

V. Phone/Fax

Practice location:
  • Phone: 847-855-2493
  • Fax: 847-855-2490
Mailing address:
  • Phone: 262-942-7250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: