Healthcare Provider Details

I. General information

NPI: 1679255889
Provider Name (Legal Business Name): COLLEEN KING GOODE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2023
Last Update Date: 08/16/2023
Certification Date: 08/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1404 S MAIN CHAPEL WAY STE 104
GAMBRILLS MD
21054-1860
US

IV. Provider business mailing address

1404 S MAIN CHAPEL WAY STE 104
GAMBRILLS MD
21054-1860
US

V. Phone/Fax

Practice location:
  • Phone: 443-814-9108
  • Fax:
Mailing address:
  • Phone: 443-814-9108
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: COLLEEN GOODE
Title or Position: OWNER
Credential:
Phone: 443-814-9108