Provider Demographics
NPI:1336466705
Name:PROVENZANO-GOBER, JULIETTE LYNN
Entity type:Individual
Prefix:MRS
First Name:JULIETTE
Middle Name:LYNN
Last Name:PROVENZANO-GOBER
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 1:45 HALF MOON LN
Mailing Address - Street 2:
Mailing Address - City:IRVINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:10533-2520
Mailing Address - Country:US
Mailing Address - Phone:914-629-2284
Mailing Address - Fax:
Practice Address - Street 1:155 WHITE PLAINS RD STE 210
Practice Address - Street 2:
Practice Address - City:TARRYTOWN
Practice Address - State:NY
Practice Address - Zip Code:10591-5653
Practice Address - Country:US
Practice Address - Phone:914-372-7171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-26
Last Update Date:2025-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY263433207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program