Provider Demographics
NPI:1598970576
Name:GOFORTH, AUDREY ANN
Entity type:Individual
Prefix:MRS
First Name:AUDREY
Middle Name:ANN
Last Name:GOFORTH
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:AUDREY
Other - Middle Name:ANN
Other - Last Name:KELBLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:123 LILLE RD
Mailing Address - Street 2:
Mailing Address - City:NASHUA
Mailing Address - State:NH
Mailing Address - Zip Code:03062-2439
Mailing Address - Country:US
Mailing Address - Phone:603-888-0605
Mailing Address - Fax:
Practice Address - Street 1:607 NORTH AVE STE 12
Practice Address - Street 2:
Practice Address - City:WAKEFIELD
Practice Address - State:MA
Practice Address - Zip Code:01880-1307
Practice Address - Country:US
Practice Address - Phone:781-245-5710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1143174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist