Healthcare Provider Details

I. General information

NPI: 1710386289
Provider Name (Legal Business Name): ROBERT GONZALEZ APN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2014
Last Update Date: 01/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 LONGFIELD CT
MONTGOMERY AL
36117-8055
US

IV. Provider business mailing address

1040 LONGFIELD CT
MONTGOMERY AL
36117-8055
US

V. Phone/Fax

Practice location:
  • Phone: 334-288-9009
  • Fax: 334-288-9497
Mailing address:
  • Phone: 334-288-9009
  • Fax: 334-288-9497

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number809089
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP126135
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number1-159176
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: