Provider Demographics
NPI:1356040018
Name:GODBOLDT, STACIA LAROSE (CNM)
Entity type:Individual
Prefix:
First Name:STACIA
Middle Name:LAROSE
Last Name:GODBOLDT
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:184 OAK SHADOW PL
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259-7425
Mailing Address - Country:US
Mailing Address - Phone:904-652-7298
Mailing Address - Fax:
Practice Address - Street 1:300 HEALTH PARK BLVD STE 3002
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-3703
Practice Address - Country:US
Practice Address - Phone:904-819-1500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-01
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife