Healthcare Provider Details

I. General information

NPI: 1063842128
Provider Name (Legal Business Name): STEPHANIE T GOODRICH RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/26/2013
Last Update Date: 03/18/2022
Certification Date: 03/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 JOHN PAUL JONES CIR
PORTSMOUTH VA
23708-2111
US

IV. Provider business mailing address

620 JOHN PAUL JONES CIR
PORTSMOUTH VA
23708-2111
US

V. Phone/Fax

Practice location:
  • Phone: 757-953-0603
  • Fax: 757-953-7478
Mailing address:
  • Phone: 757-953-0603
  • Fax: 757-953-7478

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number0001150275
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: