Basic Information
| Provider Information | |||||||||
| NPI: | 1801933742 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOETZ | ||||||||
| FirstName: | RAMONA | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 761 OLD NORCROSS RD | ||||||||
| Address2: | |||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300454317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7705134000 | ||||||||
| FaxNumber: | 7709953495 | ||||||||
| Practice Location | |||||||||
| Address1: | 761 OLD NORCROSS RD | ||||||||
| Address2: | |||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300454317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7705134000 | ||||||||
| FaxNumber: | 7709953495 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 176B00000X | RN026703 | GA | Y | Other Service Providers | Midwife |
ID Information
| ID | Type | State | Issuer | Description | 00603138A | 01 | GA | WELLCARE | OTHER | 00603138A | 05 | GA | MEDICAID |