Provider Demographics
NPI:1700495009
Name:KPORTUFE, GOLDER
Entity Type:Individual
Prefix:
First Name:GOLDER
Middle Name:
Last Name:KPORTUFE
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 1:280 PARK HILL AVE APT 6C
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10304-4612
Mailing Address - Country:US
Mailing Address - Phone:347-324-4088
Mailing Address - Fax:
Practice Address - Street 1:280 PARK HILL AVE APT 6C
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10304-4612
Practice Address - Country:US
Practice Address - Phone:347-324-4088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-23
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY793099163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse