Healthcare Provider Details

I. General information

NPI: 1255590816
Provider Name (Legal Business Name): KELLEY JO GOODELL CST/FA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2008
Last Update Date: 06/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44 FIELDS POND RD
ORRINGTON ME
04474-3333
US

IV. Provider business mailing address

44 FIELDS POND RD
ORRINGTON ME
04474-3333
US

V. Phone/Fax

Practice location:
  • Phone: 207-991-3762
  • Fax:
Mailing address:
  • Phone: 207-991-3762
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: