Healthcare Provider Details

I. General information

NPI: 1699015370
Provider Name (Legal Business Name): RAYA GOLDENBERG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2013
Last Update Date: 02/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

132 CLOCKTOWER DR APT. 4312
WALTHAM MA
02452-7873
US

IV. Provider business mailing address

132 CLOCKTOWER DRIVE APT. 4312
WALTHAM MA
02452
US

V. Phone/Fax

Practice location:
  • Phone: 617-721-4450
  • Fax:
Mailing address:
  • Phone: 617-721-4450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN262356
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: