Provider Demographics
NPI:1477634483
Name:GODWIN, STARLETTE C
Entity Type:Individual
Prefix:
First Name:STARLETTE
Middle Name:C
Last Name:GODWIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3655 MITCHELL ST
Mailing Address - Street 2:
Mailing Address - City:LORIS
Mailing Address - State:SC
Mailing Address - Zip Code:29569-2827
Mailing Address - Country:US
Mailing Address - Phone:843-716-7520
Mailing Address - Fax:
Practice Address - Street 1:3655 MITCHELL ST
Practice Address - Street 2:
Practice Address - City:LORIS
Practice Address - State:SC
Practice Address - Zip Code:29569-2827
Practice Address - Country:US
Practice Address - Phone:843-716-7520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2925367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC400649Medicaid
SCQ34282Medicare UPIN
SC400649Medicaid