Provider Demographics
NPI:1992911432
Name:GOSS, LORRAINE ANN (RN)
Entity type:Individual
Prefix:MRS
First Name:LORRAINE
Middle Name:ANN
Last Name:GOSS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1860
Mailing Address - Street 2:
Mailing Address - City:CORRALES
Mailing Address - State:NM
Mailing Address - Zip Code:87048-1860
Mailing Address - Country:US
Mailing Address - Phone:505-792-1516
Mailing Address - Fax:
Practice Address - Street 1:5 CAMINO DEL SOL ST.
Practice Address - Street 2:
Practice Address - City:CORALES
Practice Address - State:NM
Practice Address - Zip Code:87048
Practice Address - Country:US
Practice Address - Phone:505-792-1516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR14606363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMS6061Medicaid
NMS59314Medicare UPIN