Healthcare Provider Details

I. General information

NPI: 1982151841
Provider Name (Legal Business Name): DAHLIA GOULBOURNE ALEXANDER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2016
Last Update Date: 09/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 W KINGSBRIDGE RD
BRONX NY
10468-3904
US

IV. Provider business mailing address

1539 SULLIVAN TRL
TANNERSVILLE PA
18372-7890
US

V. Phone/Fax

Practice location:
  • Phone: 718-584-9000
  • Fax:
Mailing address:
  • Phone: 570-629-1239
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number581850
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN626028
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: