Healthcare Provider Details

I. General information

NPI: 1578882825
Provider Name (Legal Business Name): MICHELLE GODWIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2010
Last Update Date: 10/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

334 RT 2
SOUTH HERO VT
05486
US

IV. Provider business mailing address

13A E SHORE S
GRAND ISLE VT
05458-2427
US

V. Phone/Fax

Practice location:
  • Phone: 802-372-5377
  • Fax:
Mailing address:
  • Phone: 802-372-6435
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0033.0003577
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: