Provider Demographics
NPI:1073786935
Name:GOULDBOURNE, MARIE ANGE
Entity type:Individual
Prefix:MISS
First Name:MARIE ANGE
Middle Name:
Last Name:GOULDBOURNE
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 1:1 LYNWOOD DR
Mailing Address - Street 2:
Mailing Address - City:WESTBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11590-1113
Mailing Address - Country:US
Mailing Address - Phone:516-983-7037
Mailing Address - Fax:
Practice Address - Street 1:1 LYNWOOD DR
Practice Address - Street 2:
Practice Address - City:WESTBURY
Practice Address - State:NY
Practice Address - Zip Code:11590-1113
Practice Address - Country:US
Practice Address - Phone:516-983-7037
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-10
Last Update Date:2018-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY260350-1164W00000X
NY587076-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse