Provider Demographics
NPI:1982060380
Name:GOONEWARDENA, MALKANTHI
Entity Type:Individual
Prefix:MRS
First Name:MALKANTHI
Middle Name:
Last Name:GOONEWARDENA
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 1:260TH STREET
Mailing Address - Street 2:74-46, FLOOR2
Mailing Address - City:GLEN OAKS
Mailing Address - State:NY
Mailing Address - Zip Code:11004
Mailing Address - Country:US
Mailing Address - Phone:718-347-0542
Mailing Address - Fax:
Practice Address - Street 1:260TH STREET
Practice Address - Street 2:74-46, FLOOR2
Practice Address - City:GLEN OAKS
Practice Address - State:NY
Practice Address - Zip Code:11004
Practice Address - Country:US
Practice Address - Phone:718-347-0542
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-14
Last Update Date:2016-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY639989951174400000X
174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist