Provider Demographics
NPI:1922242718
Name:GODBOUT, FARRELL (APN)
Entity Type:Individual
Prefix:
First Name:FARRELL
Middle Name:
Last Name:GODBOUT
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 E 61ST ST
Mailing Address - Street 2:SUITE 207
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60637-2623
Mailing Address - Country:US
Mailing Address - Phone:203-980-3553
Mailing Address - Fax:
Practice Address - Street 1:1950 W ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-1245
Practice Address - Country:US
Practice Address - Phone:312-433-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-24
Last Update Date:2013-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.009305363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC193911YT2Medicare PIN
DC153342YTAMedicare PIN