Provider Demographics
NPI:1902419625
Name:GOLDMAN, MARILYN F
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:F
Last Name:GOLDMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 WILTON DR
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71202
Mailing Address - Country:US
Mailing Address - Phone:318-512-9390
Mailing Address - Fax:
Practice Address - Street 1:1001 WILTON DR
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71202
Practice Address - Country:US
Practice Address - Phone:318-512-9390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-24
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)