Healthcare Provider Details

I. General information

NPI: 1477535979
Provider Name (Legal Business Name): JERRI GOODMAN CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2005
Last Update Date: 10/31/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 N MADISON AVE
ANDERSON IN
46011-3453
US

IV. Provider business mailing address

PO BOX 68952
INDIANAPOLIS IN
46268-0952
US

V. Phone/Fax

Practice location:
  • Phone: 317-802-6302
  • Fax:
Mailing address:
  • Phone: 317-802-6302
  • Fax: 317-870-0499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number28120956
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: