Basic Information
| Provider Information | |||||||||
| NPI: | 1265621999 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOFF | ||||||||
| FirstName: | MACIE | ||||||||
| MiddleName: | LANE | ||||||||
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| Credential: | CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 221 TECHNOLOGY PKWY NW | ||||||||
| Address2: | |||||||||
| City: | ROME | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301651369 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062351000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 200 GENTILLY BLVD | ||||||||
| Address2: | |||||||||
| City: | CARTERSVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301208504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4704907200 | ||||||||
| FaxNumber: | 7702767251 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2007 | ||||||||
| LastUpdateDate: | 04/24/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | RN124928 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 000915736A | 05 | GA | MEDICAID |