Provider Demographics
NPI:1053172270
Name:GOLDBERG, EMILLY JANE (LPN)
Entity type:Individual
Prefix:
First Name:EMILLY
Middle Name:JANE
Last Name:GOLDBERG
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4003 BRIAN LN
Mailing Address - Street 2:
Mailing Address - City:EAST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11730-1476
Mailing Address - Country:US
Mailing Address - Phone:631-972-7169
Mailing Address - Fax:
Practice Address - Street 1:4003 BRIAN LN
Practice Address - Street 2:
Practice Address - City:EAST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11730-1476
Practice Address - Country:US
Practice Address - Phone:631-972-7169
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-16
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY345134164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse