Provider Demographics
NPI:1114404639
Name:GODWIN, PAMELA
Entity Type:Individual
Prefix:MISS
First Name:PAMELA
Middle Name:
Last Name:GODWIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:PAMELA
Other - Middle Name:
Other - Last Name:GODWIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4511 JACKSON ST # 4511
Mailing Address - Street 2:
Mailing Address - City:MARIANNA
Mailing Address - State:FL
Mailing Address - Zip Code:32448-4718
Mailing Address - Country:US
Mailing Address - Phone:850-557-6783
Mailing Address - Fax:
Practice Address - Street 1:4511 JACKSON ST # 4511
Practice Address - Street 2:
Practice Address - City:MARIANNA
Practice Address - State:FL
Practice Address - Zip Code:32448-4718
Practice Address - Country:US
Practice Address - Phone:850-557-6783
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-26
Last Update Date:2018-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL374U00000X, 376K00000X
376K00000X, 385HR2060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
No374U00000XNursing Service Related ProvidersHome Health Aide
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL721310Medicaid
FL$$$$$$$$$Medicaid