Provider Demographics
NPI:1386459022
Name:GODFREY, DYLAN MARIE
Entity type:Individual
Prefix:
First Name:DYLAN
Middle Name:MARIE
Last Name:GODFREY
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6819 POINTE OF WOODS DR
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33413-3803
Mailing Address - Country:US
Mailing Address - Phone:561-578-1174
Mailing Address - Fax:
Practice Address - Street 1:600 HERITAGE DR STE 105
Practice Address - Street 2:
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458-3098
Practice Address - Country:US
Practice Address - Phone:561-379-7956
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-10
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11037630363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner