Provider Demographics
NPI:1255397907
Name:GOODMAN, DIANE M (NP APRN)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:M
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:NP APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9217 73RD ST
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142
Mailing Address - Country:US
Mailing Address - Phone:262-942-7250
Mailing Address - Fax:
Practice Address - Street 1:1445 N HUNT CLUB ROAD
Practice Address - Street 2:SUITE 102
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031
Practice Address - Country:US
Practice Address - Phone:847-855-2493
Practice Address - Fax:847-855-2490
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse