Provider Demographics
NPI:1518206499
Name:GOFORTH, VICTORIA ANN (LPN)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:ANN
Last Name:GOFORTH
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:VICTORIA
Other - Middle Name:ANN
Other - Last Name:SHERLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:515 CLANTON RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28217-1309
Mailing Address - Country:US
Mailing Address - Phone:704-332-9001
Mailing Address - Fax:704-714-1182
Practice Address - Street 1:117 W MEDICAL CT
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:NC
Practice Address - Zip Code:28752-5590
Practice Address - Country:US
Practice Address - Phone:828-659-3966
Practice Address - Fax:828-659-6304
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-12
Last Update Date:2013-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC59854164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse