Healthcare Provider Details

I. General information

NPI: 1750168183
Provider Name (Legal Business Name): NICOLE MARIE GODDARD APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2023
Last Update Date: 09/11/2023
Certification Date: 09/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 FAYETTEVILLE ST
DURHAM NC
27707-3129
US

IV. Provider business mailing address

206 S NASH ST APT 125
HILLSBOROUGH NC
27278-2391
US

V. Phone/Fax

Practice location:
  • Phone: 919-530-5485
  • Fax:
Mailing address:
  • Phone: 931-217-7144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5018749
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: