Provider Demographics
NPI:1003413634
Name:GOODROW, REBA (APRN)
Entity Type:Individual
Prefix:
First Name:REBA
Middle Name:
Last Name:GOODROW
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:82 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:WOLCOTT
Mailing Address - State:CT
Mailing Address - Zip Code:06716-3002
Mailing Address - Country:US
Mailing Address - Phone:203-589-7867
Mailing Address - Fax:
Practice Address - Street 1:1 POMPERAUG OFFICE PARK STE 102&103
Practice Address - Street 2:
Practice Address - City:SOUTHBURY
Practice Address - State:CT
Practice Address - Zip Code:06488-2295
Practice Address - Country:US
Practice Address - Phone:203-558-1143
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-06
Last Update Date:2022-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT9240363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily