Basic Information
| Provider Information | |||||||||
| NPI: | 1124750815 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOODRICH | ||||||||
| FirstName: | RENEE | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | NURSE PRACTITIONER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 307 CARLSON DR | ||||||||
| Address2: | |||||||||
| City: | KNOX | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465342304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8444582800 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 307 CARLSON DR | ||||||||
| Address2: | |||||||||
| City: | KNOX | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465342304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8444582800 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2022 | ||||||||
| LastUpdateDate: | 08/28/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 28202615A | IN | N | Nursing Service Providers | Registered Nurse | 363LF0000X | 71012832A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 28202615A | 01 | IN | REGISTERED NURSE | OTHER | 71012832A | 01 | IN | APRN PRESCRIPTIVE AUTHORITY | OTHER |