Healthcare Provider Details

I. General information

NPI: 1366318354
Provider Name (Legal Business Name): GILLO GOMBEH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2025
Last Update Date: 12/20/2025
Certification Date: 12/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

91 TOMPKINS AVE
STATEN ISLAND NY
10304-2601
US

IV. Provider business mailing address

4036 PRESIDENTIAL HILL LOOP
DUMFRIES VA
22025-3632
US

V. Phone/Fax

Practice location:
  • Phone: 732-439-1170
  • Fax:
Mailing address:
  • Phone: 732-439-1170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number0024195064
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number407755
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: