Provider Demographics
NPI:1992249353
Name:GODFREY, NICOLE STROUD (FNP-C)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:STROUD
Last Name:GODFREY
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-2319
Mailing Address - Country:US
Mailing Address - Phone:800-690-6639
Mailing Address - Fax:
Practice Address - Street 1:8631 W 3RD ST STE 635E
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-5994
Practice Address - Country:US
Practice Address - Phone:310-248-8245
Practice Address - Fax:310-248-8778
Is Sole Proprietor?:No
Enumeration Date:2016-12-05
Last Update Date:2019-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201609121NP-PP363LF0000X
FLARNP9382141363LF0000X
NY33 341191363LF0000X
CA95005827363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily