Provider Demographics
NPI:1386812238
Name:GOLDBERG, JILL C (APRN)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:C
Last Name:GOLDBERG
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 BONNYBROOK RD
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06850-2703
Mailing Address - Country:US
Mailing Address - Phone:203-247-9636
Mailing Address - Fax:203-956-0570
Practice Address - Street 1:1 BONNYBROOK RD
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06850-2703
Practice Address - Country:US
Practice Address - Phone:203-247-9636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-13
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002713363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT002713OtherSTATE LICENSE