Provider Demographics
NPI:1114541976
Name:GONYEAU, ELLIE
Entity Type:Individual
Prefix:
First Name:ELLIE
Middle Name:
Last Name:GONYEAU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 DOVETAIL LN
Mailing Address - Street 2:
Mailing Address - City:COTUIT
Mailing Address - State:MA
Mailing Address - Zip Code:02635-2550
Mailing Address - Country:US
Mailing Address - Phone:518-681-1569
Mailing Address - Fax:
Practice Address - Street 1:300 BROOKLINE AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-5403
Practice Address - Country:US
Practice Address - Phone:518-681-1569
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-07
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2330144363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily