Healthcare Provider Details

I. General information

NPI: 1194208488
Provider Name (Legal Business Name): MRS. BRIDGETTE LYNN GODFREY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2018
Last Update Date: 09/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

167 SOUTH 4TH STREET
FULTON NY
13069
US

IV. Provider business mailing address

182 GILBERT MILLS ROAD
PHOENIX NY
13135
US

V. Phone/Fax

Practice location:
  • Phone: 315-963-4229
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number610009
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: