Provider Demographics
NPI:1508197815
Name:GOODMAN, VICKI L (CNM)
Entity Type:Individual
Prefix:
First Name:VICKI
Middle Name:L
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3727 W WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53208-3182
Mailing Address - Country:US
Mailing Address - Phone:414-291-2626
Mailing Address - Fax:414-431-0050
Practice Address - Street 1:3727 W WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53208-3182
Practice Address - Country:US
Practice Address - Phone:414-291-2626
Practice Address - Fax:414-431-0050
Is Sole Proprietor?:No
Enumeration Date:2010-01-26
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI148838-32176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1508197815Medicaid
WI01560-0050Medicare PIN