Provider Demographics
NPI:1194356576
Name:GOODRICH, WANDA JEAN
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:JEAN
Last Name:GOODRICH
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 1:935 STATE ROUTE VV
Mailing Address - Street 2:
Mailing Address - City:KENNETT
Mailing Address - State:MO
Mailing Address - Zip Code:63857-3822
Mailing Address - Country:US
Mailing Address - Phone:573-888-5925
Mailing Address - Fax:
Practice Address - Street 1:935 STATE ROUTE VV
Practice Address - Street 2:
Practice Address - City:KENNETT
Practice Address - State:MO
Practice Address - Zip Code:63857-3822
Practice Address - Country:US
Practice Address - Phone:573-888-5925
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-04
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007026784164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse