Provider Demographics
NPI:1780670786
Name:GODWIN, DEBRA K (NP)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:K
Last Name:GODWIN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 SOAPSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30115-6683
Mailing Address - Country:US
Mailing Address - Phone:770-720-8686
Mailing Address - Fax:
Practice Address - Street 1:3825 CHEROKEE ST NW
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-2085
Practice Address - Country:US
Practice Address - Phone:770-422-1400
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN059374363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily