Provider Demographics
NPI:1720488091
Name:MINGO, GODDESS (RN)
Entity Type:Individual
Prefix:
First Name:GODDESS
Middle Name:
Last Name:MINGO
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4923 E 109TH ST
Mailing Address - Street 2:
Mailing Address - City:GARFIELD HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44125-2230
Mailing Address - Country:US
Mailing Address - Phone:216-253-4041
Mailing Address - Fax:
Practice Address - Street 1:6001 STATE RD
Practice Address - Street 2:
Practice Address - City:PARMA
Practice Address - State:OH
Practice Address - Zip Code:44134-2869
Practice Address - Country:US
Practice Address - Phone:216-253-4041
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-24
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH156494164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse