Provider Demographics
NPI:1043205644
Name:GOFF, DANA HUMES (APN, CNM)
Entity Type:Individual
Prefix:MRS
First Name:DANA
Middle Name:HUMES
Last Name:GOFF
Suffix:
Gender:F
Credentials:APN, CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 MAIN ST STE 660
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61602-1060
Mailing Address - Country:US
Mailing Address - Phone:309-687-4230
Mailing Address - Fax:309-687-7704
Practice Address - Street 1:900 MAIN ST STE 660
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61602-1060
Practice Address - Country:US
Practice Address - Phone:309-687-4230
Practice Address - Fax:309-687-7704
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209001654367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL203448Medicare ID - Type Unspecified