Provider Demographics
NPI:1700396405
Name:GOODRUM, STEPHANNIE LORENE (APRN)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANNIE
Middle Name:LORENE
Last Name:GOODRUM
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 1:175 EVANS LN
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:KY
Mailing Address - Zip Code:42031-9402
Mailing Address - Country:US
Mailing Address - Phone:270-217-9558
Mailing Address - Fax:
Practice Address - Street 1:308 S WASHINGTON ST STE 200
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:KY
Practice Address - Zip Code:42031-1347
Practice Address - Country:US
Practice Address - Phone:270-653-0220
Practice Address - Fax:270-653-0221
Is Sole Proprietor?:No
Enumeration Date:2017-10-07
Last Update Date:2017-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3011787363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily