Provider Demographics
NPI:1124750815
Name:GOODRICH, RENEE MARIE (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:RENEE
Middle Name:MARIE
Last Name:GOODRICH
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1958 W BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46902-6078
Mailing Address - Country:US
Mailing Address - Phone:765-865-0135
Mailing Address - Fax:765-450-6744
Practice Address - Street 1:2004 W SYCAMORE ST
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46901-4112
Practice Address - Country:US
Practice Address - Phone:765-865-0135
Practice Address - Fax:765-450-6744
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-30
Last Update Date:2025-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71012832A363LF0000X
261QU0200X
IN28202615A163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN71012832AOtherAPRN PRESCRIPTIVE AUTHORITY
IN28202615AOtherREGISTERED NURSE