Crystal Wallace Goddin, PTA

Key facts

NPI

1619465481

Entity type

Individual (NPI type 1)

Primary specialty

Physical Therapy Assistant 225200000X

License

23675 (FL)

Practice address

1104 N Main St, Bushnell, FL
Bushnell, FL 33513

Phone

(352) 568-8777

NPI assigned

Apr 27, 2018

Sex

Female

Sole proprietor

No

Medicare participation

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

National Provider Directory

Medicare enrollment (NPD)

No

State licenses

Specialties & licenses

Addresses

The complete NPPES record for this NPI in the NPI Registry API JSON format, last updated by the provider on Apr 27, 2018.

{
    "created_epoch": "1524787200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1524787200000",
    "number": "1619465481",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "391 CR 549",
            "city": "BUSHNELL",
            "state": "FL",
            "postal_code": "33513",
            "telephone_number": "352-603-1380"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1104 N MAIN ST, BUSHNELL, FL",
            "city": "BUSHNELL",
            "state": "FL",
            "postal_code": "33513",
            "telephone_number": "352-568-8777"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "GODDIN",
        "first_name": "CRYSTAL",
        "middle_name": "WALLACE",
        "credential": "PTA",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2018-04-27",
        "last_updated": "2018-04-27",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "225200000X",
            "taxonomy_group": "",
            "desc": "Physical Therapy Assistant",
            "state": "FL",
            "license": "23675",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Bushnell, FL

• Kimberly Faeh
• John B. Fleming, PHD, HSPP
• Florida Department of Health
• Bahaa R Gerges, RPT
• Shelly Rene Gilbert, PTA
• Carolyn Sue Guarino, LPN II
• Jennifer Finkley Gue, FNP-C
• Gildardo Alexis Guerrero Mora, MD
• Kara Hastie, LMT
• Healthflo Medical Clinics Inc

All providers in Bushnell, FL · Physical Therapy Assistant in Florida