Provider Demographics
NPI:1841792504
Name:GOODMAN, KERRY JO (LPN)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:JO
Last Name:GOODMAN
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 1:2260 JENNIFER PL
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-4338
Mailing Address - Country:US
Mailing Address - Phone:360-518-1886
Mailing Address - Fax:
Practice Address - Street 1:305 PACIFIC AVE S STE C
Practice Address - Street 2:
Practice Address - City:KELSO
Practice Address - State:WA
Practice Address - Zip Code:98626-1638
Practice Address - Country:US
Practice Address - Phone:360-425-5378
Practice Address - Fax:360-425-5990
Is Sole Proprietor?:No
Enumeration Date:2018-03-08
Last Update Date:2018-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALP60341830164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse