Provider Demographics
NPI:1760976617
Name:GODLEY FAMILY MEDICINE CLINIC
Entity Type:Organization
Organization Name:GODLEY FAMILY MEDICINE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:JOY
Authorized Official - Middle Name:
Authorized Official - Last Name:KEETON
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:512-645-0181
Mailing Address - Street 1:PO BOX 682
Mailing Address - Street 2:
Mailing Address - City:GODLEY
Mailing Address - State:TX
Mailing Address - Zip Code:76044-0682
Mailing Address - Country:US
Mailing Address - Phone:512-645-0181
Mailing Address - Fax:512-582-8585
Practice Address - Street 1:7431 SPRING RANCH CT
Practice Address - Street 2:
Practice Address - City:GODLEY
Practice Address - State:TX
Practice Address - Zip Code:76044-3855
Practice Address - Country:US
Practice Address - Phone:512-645-0181
Practice Address - Fax:512-582-8585
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-14
Last Update Date:2018-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP126404363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1942604830OtherNPI INDIVIDUAL