Provider Demographics
NPI:1578984811
Name:GOSS, JENNY VANLORA (CNM)
Entity Type:Individual
Prefix:MRS
First Name:JENNY
Middle Name:VANLORA
Last Name:GOSS
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:JENNY
Other - Middle Name:
Other - Last Name:PIMENTEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:105 JW PLAZA DR SE STE 1
Mailing Address - Street 2:
Mailing Address - City:CALHOUN
Mailing Address - State:GA
Mailing Address - Zip Code:30701-1503
Mailing Address - Country:US
Mailing Address - Phone:706-383-5622
Mailing Address - Fax:
Practice Address - Street 1:1105 BURLEYSON RD
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-3181
Practice Address - Country:US
Practice Address - Phone:706-278-4640
Practice Address - Fax:706-275-6599
Is Sole Proprietor?:No
Enumeration Date:2014-01-03
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI114271-30163WH0200X, 163WH0200X
GARN261026367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003180417BMedicaid