Provider Demographics
NPI:1114007333
Name:GOODMAN, KARENE MARIE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:KARENE
Middle Name:MARIE
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 918
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401
Mailing Address - Country:US
Mailing Address - Phone:573-308-5044
Mailing Address - Fax:573-341-5300
Practice Address - Street 1:715 ST RT CC
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401
Practice Address - Country:US
Practice Address - Phone:573-308-5044
Practice Address - Fax:573-341-5300
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO094845363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO424960409Medicaid
MO500024104OtherRAILROAD MEDICARE
MO500024104OtherRAILROAD MEDICARE