Provider Demographics
NPI:1801426127
Name:GODBOUT, KELLEY ERIN (PA-C)
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:ERIN
Last Name:GODBOUT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5019 OLDE STONE LN
Mailing Address - Street 2:
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28104-3354
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157-4963
Practice Address - Country:US
Practice Address - Phone:336-716-2011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-10761363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant