Provider Demographics
NPI:1639915986
Name:GOSS, SIMONE
Entity type:Individual
Prefix:
First Name:SIMONE
Middle Name:
Last Name:GOSS
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 1:1040 RICHMOND PLACE WAY
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-9074
Mailing Address - Country:US
Mailing Address - Phone:860-816-2842
Mailing Address - Fax:
Practice Address - Street 1:1040 RICHMOND PLACE WAY
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-9074
Practice Address - Country:US
Practice Address - Phone:860-816-2842
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-06
Last Update Date:2024-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACN0014244097376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide