Provider Demographics
NPI:1700065505
Name:GOODMAN, JOAN MARIE (RNC, WHNP)
Entity type:Individual
Prefix:MRS
First Name:JOAN
Middle Name:MARIE
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:RNC, WHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:918 S. MEADOWBROOK DR.
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47407-4233
Mailing Address - Country:US
Mailing Address - Phone:812-332-2181
Mailing Address - Fax:812-332-2189
Practice Address - Street 1:383 S. PARK RIDGE RD.
Practice Address - Street 2:STE 102
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-8574
Practice Address - Country:US
Practice Address - Phone:812-330-5250
Practice Address - Fax:812-330-5240
Is Sole Proprietor?:No
Enumeration Date:2007-10-29
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000412A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN71000412BOtherIN PROFESSIONAL LICENSING AGENCY
IN71000412BOtherIND PROFESSIONAL LICENSIN
IN71000412BOtherIND PROFESSIONAL LICENSIN
MG0463694OtherDRUG ENFORCEMENT ADMINIST