Provider Demographics
NPI:1679954200
Name:GOODRICH, RYAN E (LPN)
Entity Type:Individual
Prefix:MISS
First Name:RYAN
Middle Name:E
Last Name:GOODRICH
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 BUTLER ST
Mailing Address - Street 2:
Mailing Address - City:WEST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11795-3527
Mailing Address - Country:US
Mailing Address - Phone:631-505-5586
Mailing Address - Fax:
Practice Address - Street 1:57 BUTLER ST
Practice Address - Street 2:
Practice Address - City:WEST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11795-3527
Practice Address - Country:US
Practice Address - Phone:631-505-5586
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-09
Last Update Date:2015-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY321231164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse