Provider Demographics
NPI:1740824572
Name:GOODSIR, KELLI ANN (RN BSN)
Entity type:Individual
Prefix:MS
First Name:KELLI
Middle Name:ANN
Last Name:GOODSIR
Suffix:
Gender:F
Credentials:RN BSN
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:ANN
Other - Last Name:MCNEIL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:530 E ELLENDALE RD UNIT 229
Mailing Address - Street 2:
Mailing Address - City:EDGERTON
Mailing Address - State:WI
Mailing Address - Zip Code:53534-8474
Mailing Address - Country:US
Mailing Address - Phone:608-289-2139
Mailing Address - Fax:
Practice Address - Street 1:530 E ELLENDALE RD UNIT 229
Practice Address - Street 2:
Practice Address - City:EDGERTON
Practice Address - State:WI
Practice Address - Zip Code:53534-8474
Practice Address - Country:US
Practice Address - Phone:608-289-2139
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-05
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI91209163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse