Healthcare Provider Details

I. General information

NPI: 1760976617
Provider Name (Legal Business Name): GODLEY FAMILY MEDICINE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2018
Last Update Date: 06/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7431 SPRING RANCH CT
GODLEY TX
76044-3855
US

IV. Provider business mailing address

PO BOX 682
GODLEY TX
76044-0682
US

V. Phone/Fax

Practice location:
  • Phone: 512-645-0181
  • Fax: 512-582-8585
Mailing address:
  • Phone: 512-645-0181
  • Fax: 512-582-8585

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP126404
License Number StateTX

VIII. Authorized Official

Name: JOY KEETON
Title or Position: OWNER/PROVIDER
Credential: FNP-C
Phone: 512-645-0181