Provider Demographics
NPI:1740752765
Name:GOFORTH, MASYN CLAIRE
Entity Type:Individual
Prefix:MS
First Name:MASYN
Middle Name:CLAIRE
Last Name:GOFORTH
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 1:150 VZCR 1920
Mailing Address - Street 2:
Mailing Address - City:FRUITVALE
Mailing Address - State:TX
Mailing Address - Zip Code:75127-1888
Mailing Address - Country:US
Mailing Address - Phone:903-941-7515
Mailing Address - Fax:
Practice Address - Street 1:150 VZCR 1920
Practice Address - Street 2:
Practice Address - City:FRUITVALE
Practice Address - State:TX
Practice Address - Zip Code:75127-1888
Practice Address - Country:US
Practice Address - Phone:903-941-7515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-02
Last Update Date:2019-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX346637164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse