Kag Professional Nurse Practitioner in Adult Health PLLC

Primary specialty

Adult Health Nurse PractitionerTaxonomy code 363LA2200X

Legal business name

KAG PROFESSIONAL NURSE PRACTITIONER IN ADULT HEALTH PLLC

Practice address

3115 Horseblock Rd
Medford, NY 11763-2526

Phone

(631) 872-2995

NPI assigned

May 17, 2019

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Kelly Ann Godberson, NPNPI 1053833962

Title

Nurse Practitioner

Phone

(631) 872-2995

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in NY

Enrollment records 1

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Kelly Ann Godberson, NP

  • Nurse Practitioner
  • Medford, NY
  • NPI 1053833962
  Medicare reassignment NPD Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1558051200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1666569600000",
    "number": "1295391985",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "32 MARLIN RD",
            "city": "CENTEREACH",
            "state": "NY",
            "postal_code": "117203012",
            "telephone_number": "631-872-2995"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3115 HORSEBLOCK RD",
            "city": "MEDFORD",
            "state": "NY",
            "postal_code": "117632526",
            "telephone_number": "631-872-2995"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "KAG PROFESSIONAL NURSE PRACTITIONER IN ADULT HEALTH PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-05-17",
        "last_updated": "2022-10-24",
        "certification_date": "2022-07-14",
        "status": "A",
        "authorized_official_last_name": "GODBERSON",
        "authorized_official_first_name": "KELLY",
        "authorized_official_middle_name": "ANN",
        "authorized_official_title_or_position": "NURSE PRACTITIONER",
        "authorized_official_telephone_number": "631-872-2995",
        "authorized_official_credential": "NP"
    },
    "taxonomies": [
        {
            "code": "363LA2200X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Nurse Practitioner, Adult Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Theresa Ann Johnson, RN
• Vivian A Johnson, RN
• Jennifer Ami Jones, MA-CCC-SLP
• Ernite Joseph
• Judy Joseph, LMSW
• Henry Fiaz Kahn
• Mark Barry Kahn, D.M.D.
• Kahn,Kahn,Kahn
• Kelsey Rose Kalafut, LMSW
• Delores Kalakowski

• Adult Health Nurse Practitioner in Medford, NY
• Providers in Medford, NY by specialty
• Adult Health Nurse Practitioner in New York

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 24, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.