Healthcare Provider Details

I. General information

NPI: 1306403209
Provider Name (Legal Business Name): ELISABETH A GOEBEL RN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2019
Last Update Date: 10/03/2022
Certification Date: 10/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11804 W SHERIAC ST
WICHITA KS
67209-6720
US

IV. Provider business mailing address

11804 W SHERIAC ST
WICHITA KS
67209-2915
US

V. Phone/Fax

Practice location:
  • Phone: 316-202-8264
  • Fax:
Mailing address:
  • Phone: 316-202-8264
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number111767
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: