Provider Demographics
NPI:1699305839
Name:GODWIN, SAMUEL C (NP)
Entity type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:C
Last Name:GODWIN
Suffix:
Gender:
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8801 S 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90305-2429
Mailing Address - Country:US
Mailing Address - Phone:323-347-0008
Mailing Address - Fax:
Practice Address - Street 1:10024 S VERMONT AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90044-3112
Practice Address - Country:US
Practice Address - Phone:213-471-5026
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-15
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV877201363LP0808X
CA95013690363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health