Provider Demographics
NPI:1740871755
Name:GODBOLT, TANISHA
Entity type:Individual
Prefix:
First Name:TANISHA
Middle Name:
Last Name:GODBOLT
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 1:9147 MOSS COVE CT
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28227-8703
Mailing Address - Country:US
Mailing Address - Phone:832-794-7264
Mailing Address - Fax:
Practice Address - Street 1:9147 MOSS COVE CT
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28227-8703
Practice Address - Country:US
Practice Address - Phone:832-794-7264
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-02
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT054857335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier