Provider Demographics
NPI:1417659798
Name:GOFORTH, KALI MICHELLE I (LPN)
Entity Type:Individual
Prefix:
First Name:KALI
Middle Name:MICHELLE
Last Name:GOFORTH
Suffix:I
Gender:F
Credentials:LPN
Other - Prefix:MS
Other - First Name:KALI
Other - Middle Name:MICHELLE
Other - Last Name:GOFORTH
Other - Suffix:I
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:231 E GRAHAM AVE
Mailing Address - Street 2:
Mailing Address - City:PRYOR
Mailing Address - State:OK
Mailing Address - Zip Code:74361-2436
Mailing Address - Country:US
Mailing Address - Phone:918-232-2844
Mailing Address - Fax:
Practice Address - Street 1:231 E GRAHAM AVE
Practice Address - Street 2:
Practice Address - City:PRYOR
Practice Address - State:OK
Practice Address - Zip Code:74361-2436
Practice Address - Country:US
Practice Address - Phone:918-825-1405
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-20
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKL0071516164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse