1578984811 NPI number — MRS. JENNY VANLORA GOSS CNM

Table of content: MRS. JENNY VANLORA GOSS CNM (NPI 1578984811)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578984811 NPI number — MRS. JENNY VANLORA GOSS CNM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOSS
Provider First Name:
JENNY
Provider Middle Name:
VANLORA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
CNM
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PIMENTEL
Provider Other First Name:
JENNY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
RN
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1578984811
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/04/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
105 JW PLAZA DR SE STE 1
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CALHOUN
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30701-1503
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-383-5622
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1105 BURLEYSON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DALTON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30720-3181
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-278-4640
Provider Business Practice Location Address Fax Number:
706-275-6599
Provider Enumeration Date:
01/03/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163WH0200X , with the licence number:  114271-30 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367A00000X , with the licence number: RN261026 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 003180417B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com