Provider Demographics
NPI:1588774434
Name:GODFREY, MERLENE (GNP)
Entity type:Individual
Prefix:
First Name:MERLENE
Middle Name:
Last Name:GODFREY
Suffix:
Gender:F
Credentials:GNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:385 SENECA AVE
Mailing Address - Street 2:
Mailing Address - City:REDWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11385
Mailing Address - Country:US
Mailing Address - Phone:718-749-1216
Mailing Address - Fax:718-453-3634
Practice Address - Street 1:374 STOCKHOLM ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11237-4006
Practice Address - Country:US
Practice Address - Phone:718-486-4221
Practice Address - Fax:718-508-4632
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF340141363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02367375Medicaid
0067G1Medicare ID - Type Unspecified
NY02367375Medicaid