Provider Demographics
NPI:1912141565
Name:GOENNER, DONNA M (OPTICIAN)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:M
Last Name:GOENNER
Suffix:
Gender:F
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 MIDDLE COUNTRY RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLE ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:11953-2542
Mailing Address - Country:US
Mailing Address - Phone:631-345-0065
Mailing Address - Fax:631-345-0138
Practice Address - Street 1:750 MIDDLE COUNTRY RD
Practice Address - Street 2:
Practice Address - City:MIDDLE ISLAND
Practice Address - State:NY
Practice Address - Zip Code:11953-2542
Practice Address - Country:US
Practice Address - Phone:631-345-0065
Practice Address - Fax:631-345-0138
Is Sole Proprietor?:No
Enumeration Date:2009-04-27
Last Update Date:2009-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005432-1156F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156F00000XEye and Vision Services ProvidersTechnician/Technologist