Provider Demographics
NPI:1538259262
Name:GOULD, DOROTHY A (APN)
Entity type:Individual
Prefix:MS
First Name:DOROTHY
Middle Name:A
Last Name:GOULD
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 191
Mailing Address - Street 2:PROVIDER ENROLLMENT DEPT
Mailing Address - City:ROCKLAND
Mailing Address - State:DE
Mailing Address - Zip Code:19732-0191
Mailing Address - Country:US
Mailing Address - Phone:302-651-6212
Mailing Address - Fax:302-651-4945
Practice Address - Street 1:VIRTUA AND DUPONT CHILDRENS HEALTH PROGRAM
Practice Address - Street 2:1000 WHITE HORSE ROAD SUITE 204
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-4406
Practice Address - Country:US
Practice Address - Phone:856-309-8508
Practice Address - Fax:856-309-8556
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2016-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJNR05622800363L00000X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ22616Medicaid
MD4040228Medicaid
NJ22616Medicaid
090686ROTMedicare PIN