Provider Demographics
NPI:1528422094
Name:GONSALVES, MARYKNOLL TAURO
Entity type:Individual
Prefix:
First Name:MARYKNOLL
Middle Name:TAURO
Last Name:GONSALVES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARYKNOLL
Other - Middle Name:BULATAO
Other - Last Name:TAURO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:11406 QUEENS BLVD
Mailing Address - Street 2:APT.D5
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-7001
Mailing Address - Country:US
Mailing Address - Phone:631-747-0815
Mailing Address - Fax:
Practice Address - Street 1:11406 QUEENS BLVD
Practice Address - Street 2:APT.D5
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-7001
Practice Address - Country:US
Practice Address - Phone:631-747-0815
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-11
Last Update Date:2016-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY559705163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse