Provider Demographics
NPI:1770123366
Name:GOUBEAUD, MIN
Entity type:Individual
Prefix:
First Name:MIN
Middle Name:
Last Name:GOUBEAUD
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 1:9 PENROSE PATH
Mailing Address - Street 2:
Mailing Address - City:E NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11731-6319
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8 LANDING CT
Practice Address - Street 2:
Practice Address - City:DIX HILLS
Practice Address - State:NY
Practice Address - Zip Code:11746-5643
Practice Address - Country:US
Practice Address - Phone:516-467-7214
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-10
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY462671163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse