Provider Demographics
NPI:1962519157
Name:SHANNON-GOODRICH, EDITH RACHEL (CRNA, APNP)
Entity type:Individual
Prefix:MS
First Name:EDITH RACHEL
Middle Name:
Last Name:SHANNON-GOODRICH
Suffix:
Gender:F
Credentials:CRNA, APNP
Other - Prefix:
Other - First Name:E RACHEL, EDITH ANNE
Other - Middle Name:
Other - Last Name:GRAY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CRNA APNP
Mailing Address - Street 1:333 E 2ND ST
Mailing Address - Street 2:
Mailing Address - City:RICHLAND CENTER
Mailing Address - State:WI
Mailing Address - Zip Code:53581-1914
Mailing Address - Country:US
Mailing Address - Phone:608-647-6321
Mailing Address - Fax:
Practice Address - Street 1:333 E 2ND ST
Practice Address - Street 2:
Practice Address - City:RICHLAND CENTER
Practice Address - State:WI
Practice Address - Zip Code:53581-1914
Practice Address - Country:US
Practice Address - Phone:608-647-6321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2009-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1117-033367500000X
WI66434-030367500000X
WI019393367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered