Healthcare Provider Details

I. General information

NPI: 1619183746
Provider Name (Legal Business Name): PAMELA JANE GOODRICH LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 LOMBARD LN
SOUTH HERO VT
05486-4302
US

IV. Provider business mailing address

165 WENTWORTH ROAD
COLCHESTER VT
05446
US

V. Phone/Fax

Practice location:
  • Phone: 802-372-4123
  • Fax:
Mailing address:
  • Phone: 802-878-3178
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number0250008725
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: