Provider Demographics
NPI:1144972506
Name:BURKE-GODWIN, ADRIENNE M
Entity type:Individual
Prefix:
First Name:ADRIENNE
Middle Name:M
Last Name:BURKE-GODWIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 GLASS ST NE
Mailing Address - Street 2:
Mailing Address - City:LIVE OAK
Mailing Address - State:FL
Mailing Address - Zip Code:32064-3513
Mailing Address - Country:US
Mailing Address - Phone:386-965-6447
Mailing Address - Fax:
Practice Address - Street 1:712 GLASS ST NE
Practice Address - Street 2:
Practice Address - City:LIVE OAK
Practice Address - State:FL
Practice Address - Zip Code:32064-3513
Practice Address - Country:US
Practice Address - Phone:386-965-6447
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-26
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)