Provider Demographics
NPI:1023394442
Name:GOODRICH, DEMARA ANDREA (APRN)
Entity Type:Individual
Prefix:MRS
First Name:DEMARA
Middle Name:ANDREA
Last Name:GOODRICH
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 1:1225 FAIRWAY ST
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42103-2477
Mailing Address - Country:US
Mailing Address - Phone:270-781-3910
Mailing Address - Fax:270-796-3502
Practice Address - Street 1:1225 FAIRWAY ST
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42103-2477
Practice Address - Country:US
Practice Address - Phone:270-781-3910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-31
Last Update Date:2014-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3007091363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily