Provider Demographics
NPI:1841996766
Name:GODBOUT, ROBERT COLEMAN (LPN)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:COLEMAN
Last Name:GODBOUT
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6040 PUBLIC LANDING RD
Mailing Address - Street 2:
Mailing Address - City:SNOW HILL
Mailing Address - State:MD
Mailing Address - Zip Code:21863-2453
Mailing Address - Country:US
Mailing Address - Phone:410-632-1100
Mailing Address - Fax:
Practice Address - Street 1:6040 PUBLIC LANDING RD
Practice Address - Street 2:
Practice Address - City:SNOW HILL
Practice Address - State:MD
Practice Address - Zip Code:21863-2453
Practice Address - Country:US
Practice Address - Phone:410-632-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-02
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLP50483164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse