Provider Demographics
NPI:1982151841
Name:GOULBOURNE ALEXANDER, DAHLIA
Entity Type:Individual
Prefix:
First Name:DAHLIA
Middle Name:
Last Name:GOULBOURNE ALEXANDER
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 1:1539 SULLIVAN TRL
Mailing Address - Street 2:
Mailing Address - City:TANNERSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18372-7890
Mailing Address - Country:US
Mailing Address - Phone:570-629-1239
Mailing Address - Fax:
Practice Address - Street 1:130 W KINGSBRIDGE RD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10468-3904
Practice Address - Country:US
Practice Address - Phone:718-584-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-07
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY581850163W00000X
PARN626028163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse