Provider Demographics
NPI:1942278510
Name:GODDARD, CHERYL (CRNP)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:
Last Name:GODDARD
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1067 UPNOR RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21212-4021
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9109 LIBERTY RD
Practice Address - Street 2:
Practice Address - City:RANDALLSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21133-3521
Practice Address - Country:US
Practice Address - Phone:410-655-7373
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR087591363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD64769601OtherCAREFIRST BC OF MD IND #
DC0119OtherCAREFIRST BC OF NCA IND #
MDKQ54M761Medicare ID - Type Unspecified
DC0119OtherCAREFIRST BC OF NCA IND #