1609346501 NPI number — MARY ELIZABETH GOULD RN BSN PHN

Table of content: MARY ELIZABETH GOULD RN BSN PHN (NPI 1609346501)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609346501 NPI number — MARY ELIZABETH GOULD RN BSN PHN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOULD
Provider First Name:
MARY
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RN BSN PHN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
REIMANN
Provider Other First Name:
MARY
Provider Other Middle Name:
ELIZABETH
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
RN BSN PHN
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1609346501
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/04/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12780 BIG BEND WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VALLEY CENTER
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92082-6450
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-505-0420
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1234 ARCADIA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VISTA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92084-3404
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-310-8319
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/04/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163WS0200X , with the licence number:  369948 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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