Provider Demographics
NPI:1285136093
Name:GODWIN, KELLY LEDOUX (PA-C)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:LEDOUX
Last Name:GODWIN
Suffix:
Gender:
Credentials:PA-C
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1601 OWEN DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-3425
Mailing Address - Country:US
Mailing Address - Phone:910-678-0100
Mailing Address - Fax:910-678-7022
Practice Address - Street 1:1601 OWEN DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3425
Practice Address - Country:US
Practice Address - Phone:910-678-0100
Practice Address - Fax:910-678-7022
Is Sole Proprietor?:No
Enumeration Date:2018-03-07
Last Update Date:2025-05-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC0010-07941363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant