Individual
MRS. KELLY ANN GODBERSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
NP
Contact information
Practice address
3115 HORSEBLOCK RD, MEDFORD, NY 11763-2526
(631) 730-3000
Mailing address
32 MARLIN RD, CENTEREACH, NY 11720-3012
(631) 698-2823
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
Primary
308240
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
308240
NURSE PRACTIONER LICENSE
NY
Enumeration date
07/12/2017
Last updated
07/12/2017
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