Provider Demographics
NPI:1255779203
Name:GOSTON, ERNESTINE DELORES
Entity type:Individual
Prefix:MRS
First Name:ERNESTINE
Middle Name:DELORES
Last Name:GOSTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ERNESTINE
Other - Middle Name:DELORES
Other - Last Name:AUSTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PEER SPECIALIST
Mailing Address - Street 1:216 JAMES ST
Mailing Address - Street 2:DESC
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98104
Mailing Address - Country:US
Mailing Address - Phone:206-823-6193
Mailing Address - Fax:206-652-1236
Practice Address - Street 1:216 JAMES ST
Practice Address - Street 2:DESC
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104
Practice Address - Country:US
Practice Address - Phone:206-823-6193
Practice Address - Fax:206-652-1236
Is Sole Proprietor?:No
Enumeration Date:2013-06-12
Last Update Date:2018-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
WACG60527397175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No172V00000XOther Service ProvidersCommunity Health Worker