Healthcare Provider Details

I. General information

NPI: 1114007333
Provider Name (Legal Business Name): KARENE MARIE GOODMAN NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 02/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

715 ST RT CC
ROLLA MO
65401
US

IV. Provider business mailing address

PO BOX 918
ROLLA MO
65401
US

V. Phone/Fax

Practice location:
  • Phone: 573-308-5044
  • Fax: 573-341-5300
Mailing address:
  • Phone: 573-308-5044
  • Fax: 573-341-5300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number094845
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: