Provider Demographics
NPI:1558955831
Name:GOODMAN, EMILY (CPNP)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2650 RIDGE AVE.
Mailing Address - Street 2:DEPARTMENT OF PEDIATRICS
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-1781
Mailing Address - Country:US
Mailing Address - Phone:847-570-2033
Mailing Address - Fax:
Practice Address - Street 1:2650 RIDGE AVE.
Practice Address - Street 2:DEPARTMENT OF PEDIATRICS
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-1781
Practice Address - Country:US
Practice Address - Phone:847-570-2033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-26
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN290081363LP0200X
IL209024926363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARN290081Medicaid