Provider Demographics
NPI:1336474907
Name:GODLY, KATHRYN MICHELLE (PA)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:MICHELLE
Last Name:GODLY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1800 MARTIN LUTHER KING PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-3500
Mailing Address - Country:US
Mailing Address - Phone:919-578-2323
Mailing Address - Fax:833-264-1971
Practice Address - Street 1:1800 MARTIN LUTHER KING PKWY STE 100
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707
Practice Address - Country:US
Practice Address - Phone:919-578-2323
Practice Address - Fax:833-264-1971
Is Sole Proprietor?:No
Enumeration Date:2009-10-15
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-03453363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical