Healthcare Provider Details

I. General information

NPI: 1154163152
Provider Name (Legal Business Name): NICOLE MARIE GOGGIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2024
Last Update Date: 06/10/2024
Certification Date: 06/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 BAGBY POINT RD APT H
JACKSON TN
38305-5304
US

IV. Provider business mailing address

10 BAGBY POINT RD APT H
JACKSON TN
38305-5304
US

V. Phone/Fax

Practice location:
  • Phone: 979-219-2880
  • Fax:
Mailing address:
  • Phone: 979-219-2880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number3202
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: