Healthcare Provider Details

I. General information

NPI: 1700396405
Provider Name (Legal Business Name): STEPHANNIE LORENE GOODRUM APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2017
Last Update Date: 10/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 S WASHINGTON ST STE 200
CLINTON KY
42031-1347
US

IV. Provider business mailing address

175 EVANS LN
CLINTON KY
42031-9402
US

V. Phone/Fax

Practice location:
  • Phone: 270-653-0220
  • Fax: 270-653-0221
Mailing address:
  • Phone: 270-217-9558
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3011787
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: