Healthcare Provider Details

I. General information

NPI: 1780836395
Provider Name (Legal Business Name): IMELDA GODBOLD RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2008
Last Update Date: 10/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 W 4TH ST SUITE 100-A
MISHAWAKA IN
46544-1948
US

IV. Provider business mailing address

6864 FIR RD
BREMEN IN
46506-9718
US

V. Phone/Fax

Practice location:
  • Phone: 574-252-0317
  • Fax: 574-472-3694
Mailing address:
  • Phone: 574-342-6015
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number28170434A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: