Provider Demographics
NPI:1144560756
Name:GODLEY, ROXANNE WYNNE (MS, RD, LDN)
Entity type:Individual
Prefix:MRS
First Name:ROXANNE
Middle Name:WYNNE
Last Name:GODLEY
Suffix:
Gender:F
Credentials:MS, RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:TARBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27886-2011
Mailing Address - Country:US
Mailing Address - Phone:252-641-8286
Mailing Address - Fax:
Practice Address - Street 1:111 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:TARBORO
Practice Address - State:NC
Practice Address - Zip Code:27886-2011
Practice Address - Country:US
Practice Address - Phone:252-641-8286
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-19
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL004100133V00000X
NC86004119133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered