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1689802068 NPI number — HEATHER MARIE GOODWIN MANCEBO

NPI Number: 1689802068
Health Care Provider/Practitioner: HEATHER MARIE GOODWIN MANCEBO

Information about “1689802068” NPI (HEATHER MARIE GOODWIN MANCEBO) exists in 1689802068 in HTML format HTML  |  1689802068 in plain Text format TXT  |  1689802068 in PDF (Portable Document Format) PDF  |  1689802068 in an XML format XML  formats.

NPI Number : 1689802068 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1689802068",
    "EntityType": "Individual",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": "N",
    "IsOrgSubpart": null,
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": null,
    "LastName": "MANCEBO",
    "FirstName": "HEATHER",
    "MiddleName": "MARIE GOODWIN",
    "NamePrefix": null,
    "NameSuffix": null,
    "Credential": null,
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": null,
    "OtherLastName": null,
    "OtherFirstName": null,
    "OtherMiddleName": null,
    "OtherNamePrefix": null,
    "OtherNameSuffix": null,
    "OtherCredential": null,
    "OtherLastNameTypeCode": null,
    "FirstLineMailingAddress": "296 HAMBY LN",
    "SecondLineMailingAddress": null,
    "MailingAddressCityName": "SOCIAL CIRCLE",
    "MailingAddressStateName": "GA",
    "MailingAddressPostalCode": "30025-4851",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": null,
    "MailingAddressFaxNumber": null,
    "FirstLinePracticeLocationAddress": "2130 W SPRING STREET, SUITE 300",
    "SecondLinePracticeLocationAddress": null,
    "PracticeLocationAddressCityName": "MONROE",
    "PracticeLocationAddressStateName": "GA",
    "PracticeLocationAddressPostalCode": "30655",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "678-905-9121",
    "PracticeLocationAddressFaxNumber": null,
    "EnumerationDate": "06/24/2009",
    "LastUpdateDate": "08/18/2023",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": "F",
    "Gender": "Female",
    "AuthorizedOfficialLastName": null,
    "AuthorizedOfficialFirstName": null,
    "AuthorizedOfficialMiddleName": null,
    "AuthorizedOfficialTitle": null,
    "AuthorizedOfficialNamePrefix": null,
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": null,
    "AuthorizedOfficialTelephoneNumber": null,
    "Taxonomies": {
      "Taxonomy": [
        {
          "TaxonomyCode": "207Q00000X",
          "TaxonomyName": "Family Medicine Physician",
          "LicenseNumber": "282980",
          "LicenseNumberStateCode": "NY",
          "PrimaryTaxonomySwitch": "N"
        },
        {
          "TaxonomyCode": "207Q00000X",
          "TaxonomyName": "Family Medicine Physician",
          "LicenseNumber": "D0074885",
          "LicenseNumberStateCode": "MD",
          "PrimaryTaxonomySwitch": "N"
        },
        {
          "TaxonomyCode": "207Q00000X",
          "TaxonomyName": "Family Medicine Physician",
          "LicenseNumber": "96784",
          "LicenseNumberStateCode": "GA",
          "PrimaryTaxonomySwitch": "Y"
        }
      ]
    },
    "HealthcareProviderTaxonomyGroups": null
  }
}
                
            

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