Healthcare Provider Details

I. General information

NPI: 1366247157
Provider Name (Legal Business Name): KYNAN GOLDSBY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2025
Last Update Date: 02/15/2025
Certification Date: 02/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 S PRESTON ST
LOUISVILLE KY
40202-1701
US

IV. Provider business mailing address

508 KIRKLAND RD
CHEHALIS WA
98532-8787
US

V. Phone/Fax

Practice location:
  • Phone: 502-852-5096
  • Fax:
Mailing address:
  • Phone: 360-827-0309
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: