Healthcare Provider Details

I. General information

NPI: 1578984811
Provider Name (Legal Business Name): JENNY VANLORA GOSS CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNY PIMENTEL RN

II. Dates (important events)

Enumeration Date: 01/03/2014
Last Update Date: 10/04/2021
Certification Date: 10/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1105 BURLEYSON RD
DALTON GA
30720-3181
US

IV. Provider business mailing address

105 JW PLAZA DR SE STE 1
CALHOUN GA
30701-1503
US

V. Phone/Fax

Practice location:
  • Phone: 706-278-4640
  • Fax: 706-275-6599
Mailing address:
  • Phone: 706-383-5622
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number114271-30
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberRN261026
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: