Provider Demographics
NPI:1124854476
Name:GODDARD, KELLY (LVN)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:GODDARD
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:718 WORKMAN ST
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93307-6800
Mailing Address - Country:US
Mailing Address - Phone:661-335-7100
Mailing Address - Fax:
Practice Address - Street 1:718 WORKMAN ST
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93307-6800
Practice Address - Country:US
Practice Address - Phone:661-335-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-12
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA269864164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1568219855OtherTELECARE