Healthcare Provider Details

I. General information

NPI: 1356040018
Provider Name (Legal Business Name): STACIA LAROSE GODBOLDT CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2023
Last Update Date: 03/02/2023
Certification Date: 03/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 HEALTH PARK BLVD STE 3002
ST AUGUSTINE FL
32086-3703
US

IV. Provider business mailing address

184 OAK SHADOW PL
SAINT JOHNS FL
32259-7425
US

V. Phone/Fax

Practice location:
  • Phone: 904-819-1500
  • Fax:
Mailing address:
  • Phone: 904-652-7298
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: