Provider Demographics
NPI:1780836395
Name:GODBOLD, IMELDA (RN)
Entity Type:Individual
Prefix:
First Name:IMELDA
Middle Name:
Last Name:GODBOLD
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6864 FIR RD
Mailing Address - Street 2:
Mailing Address - City:BREMEN
Mailing Address - State:IN
Mailing Address - Zip Code:46506-9718
Mailing Address - Country:US
Mailing Address - Phone:574-342-6015
Mailing Address - Fax:
Practice Address - Street 1:420 W 4TH ST
Practice Address - Street 2:SUITE 100-A
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46544-1948
Practice Address - Country:US
Practice Address - Phone:574-252-0317
Practice Address - Fax:574-472-3694
Is Sole Proprietor?:No
Enumeration Date:2008-10-14
Last Update Date:2008-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28170434A163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management