Provider Demographics
NPI:1003397944
Name:GOULBOURNE-SMITH, ANDREA ANNMARIE (APRN, PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:ANNMARIE
Last Name:GOULBOURNE-SMITH
Suffix:
Gender:F
Credentials:APRN, PMHNP-BC
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:ANNMARIE
Other - Last Name:GOULBOURNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1400 E OAKLAND PARK BLVD STE 210
Mailing Address - Street 2:
Mailing Address - City:OAKLAND PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33334-4400
Mailing Address - Country:US
Mailing Address - Phone:954-561-6222
Mailing Address - Fax:954-990-7650
Practice Address - Street 1:7369 SHERIDAN ST STE 101
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33024-2776
Practice Address - Country:US
Practice Address - Phone:954-561-6222
Practice Address - Fax:954-990-7650
Is Sole Proprietor?:No
Enumeration Date:2018-08-28
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2935672363LF0000X
FLAPRN2935672363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL109518100Medicaid