Provider Demographics
NPI:1790101640
Name:GOFF, GLENDA
Entity Type:Individual
Prefix:
First Name:GLENDA
Middle Name:
Last Name:GOFF
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 1:1931 INDUSTRIAL PARK RD
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-5482
Mailing Address - Country:US
Mailing Address - Phone:843-915-8800
Mailing Address - Fax:843-915-6504
Practice Address - Street 1:1931 INDUSTRIAL PARK RD
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-5482
Practice Address - Country:US
Practice Address - Phone:843-915-8800
Practice Address - Fax:843-915-6504
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-14
Last Update Date:2014-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19617163W00000X, 163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health