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General NPI Number Information
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NPI Number | 1689802068
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Entity Type | Individual
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Provider Name | HEATHER MARIE GOODWIN MANCEBO
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Gender | Female
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Dates
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Enumeration Date | 06/24/2009
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Last Update Date | 08/18/2023
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Provider Practice Location Address
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Address Line | 2130 W SPRING STREET, SUITE 300
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City | MONROE
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State | GA
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Zip | 30655
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Country | US
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Telephone | 678-905-9121
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Fax |
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Provider Business Mailing Address
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Address Line | 296 HAMBY LN
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City | SOCIAL CIRCLE
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State | GA
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Zip | 30025-4851
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 282980
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | D0074885
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License Number State | MD
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Taxonomy #3
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 96784
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License Number State | GA
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