Provider Demographics
NPI:1073802302
Name:GOODMAN, VICTORIA L (LPN)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:L
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:227 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FESTUS
Mailing Address - State:MO
Mailing Address - Zip Code:63028-1952
Mailing Address - Country:US
Mailing Address - Phone:636-321-0101
Mailing Address - Fax:636-296-0101
Practice Address - Street 1:227 E MAIN ST
Practice Address - Street 2:
Practice Address - City:FESTUS
Practice Address - State:MO
Practice Address - Zip Code:63028-1952
Practice Address - Country:US
Practice Address - Phone:636-321-0101
Practice Address - Fax:636-296-0101
Is Sole Proprietor?:No
Enumeration Date:2011-04-07
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010032651164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse