Provider Demographics
NPI:1134573728
Name:GODBOLT, RUBY
Entity type:Individual
Prefix:
First Name:RUBY
Middle Name:
Last Name:GODBOLT
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 1:7001 JOHNNYCAKE RD STE 103
Mailing Address - Street 2:
Mailing Address - City:WINDSOR MILL
Mailing Address - State:MD
Mailing Address - Zip Code:21244-2419
Mailing Address - Country:US
Mailing Address - Phone:410-304-3232
Mailing Address - Fax:410-630-3853
Practice Address - Street 1:7001 JOHNNYCAKE RD STE 103
Practice Address - Street 2:
Practice Address - City:WINDSOR MILL
Practice Address - State:MD
Practice Address - Zip Code:21244-2419
Practice Address - Country:US
Practice Address - Phone:410-304-3232
Practice Address - Fax:410-630-3853
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-20
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR109843163W00000X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No163W00000XNursing Service ProvidersRegistered Nurse