Healthcare Provider Details

I. General information

NPI: 1609346501
Provider Name (Legal Business Name): MARY ELIZABETH GOULD RN BSN PHN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY ELIZABETH REIMANN RN BSN PHN

II. Dates (important events)

Enumeration Date: 12/04/2018
Last Update Date: 12/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1234 ARCADIA AVE
VISTA CA
92084-3404
US

IV. Provider business mailing address

12780 BIG BEND WAY
VALLEY CENTER CA
92082-6450
US

V. Phone/Fax

Practice location:
  • Phone: 760-310-8319
  • Fax:
Mailing address:
  • Phone: 760-505-0420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number369948
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: