Provider Demographics
NPI:1538561113
Name:GOUDREAU, SARRAH (NP)
Entity type:Individual
Prefix:
First Name:SARRAH
Middle Name:
Last Name:GOUDREAU
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3799
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-3799
Mailing Address - Country:US
Mailing Address - Phone:931-245-7013
Mailing Address - Fax:
Practice Address - Street 1:223 BURLEY AVE
Practice Address - Street 2:
Practice Address - City:HOPKINSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42240-8725
Practice Address - Country:US
Practice Address - Phone:270-887-6565
Practice Address - Fax:270-887-6575
Is Sole Proprietor?:No
Enumeration Date:2014-09-25
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN19136363L00000X
KY3011011363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100470780Medicaid
KY7100470780Medicaid