Healthcare Provider Details

I. General information

NPI: 1760128110
Provider Name (Legal Business Name): KENNEDY RENEE GOATES LVN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2022
Last Update Date: 05/09/2022
Certification Date: 05/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11123 US HIGHWAY 96 N
BROOKELAND TX
75931-5402
US

IV. Provider business mailing address

11123 US HIGHWAY 96 N
BROOKELAND TX
75931-5402
US

V. Phone/Fax

Practice location:
  • Phone: 409-594-3146
  • Fax:
Mailing address:
  • Phone: 409-594-3146
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number1065714
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: