MEDICARE: RUBY GODBOLT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	R109843	MD
2	363LG0600X	Gerontology Nurse Practitioner	R109843	MD

General Provider Information

NPI Number	:	1134573728
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RUBY GODBOLT

Provider Business Mailing Address
First Line	:	7001 JOHNNYCAKE RD STE 103
Second Line	:
City	:	WINDSOR MILL
State	:	MD
Zip	:	21244-2419
Country	:	US
Telephone Number	:	410-304-3232
Fax Number	:	410-630-3853

Provider Business Practice Location Address
First Line	:	7001 JOHNNYCAKE RD STE 103
Second Line	:
City	:	WINDSOR MILL
State	:	MD
Zip	:	21244-2419
Country	:	US
Telephone Number	:	410-304-3232
Fax Number	:	410-630-3853

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/20/2016
Last Update Date	:	04/26/2022

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Directions to “ RUBY GODBOLT ” Practice Location

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