Provider Demographics
NPI:1073603296
Name:GOODING, MARY KEYS (LPN)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:KEYS
Last Name:GOODING
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7251 MOONTOWN RD
Mailing Address - Street 2:
Mailing Address - City:APPLING
Mailing Address - State:GA
Mailing Address - Zip Code:30802-2405
Mailing Address - Country:US
Mailing Address - Phone:706-541-0106
Mailing Address - Fax:
Practice Address - Street 1:6420 POLLARDS POND RD
Practice Address - Street 2:
Practice Address - City:APPLING
Practice Address - State:GA
Practice Address - Zip Code:30802-3726
Practice Address - Country:US
Practice Address - Phone:706-541-1318
Practice Address - Fax:706-541-0753
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN042507164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse