Provider Demographics
NPI:1598256158
Name:GOBOURNE, RUTH
Entity Type:Individual
Prefix:
First Name:RUTH
Middle Name:
Last Name:GOBOURNE
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 1:7969 OAK RUN CIR
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33809-7253
Mailing Address - Country:US
Mailing Address - Phone:863-608-0559
Mailing Address - Fax:
Practice Address - Street 1:7969 OAK RUN CIR
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33809-7253
Practice Address - Country:US
Practice Address - Phone:863-608-0559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-18
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9186048363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty