Provider Demographics
NPI:1023518156
Name:GONYEA, JILLIAN (LAT, ATC)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:
Last Name:GONYEA
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3609 SW DURHAM DR
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-6507
Mailing Address - Country:US
Mailing Address - Phone:919-403-3057
Mailing Address - Fax:
Practice Address - Street 1:3609 SW DURHAM DR
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-6507
Practice Address - Country:US
Practice Address - Phone:919-403-3057
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-15
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
NCLAT-39292255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Multi-Specialty