Healthcare Provider Details

I. General information

NPI: 1689317166
Provider Name (Legal Business Name): ELOISE MARIA GONZALES APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2022
Last Update Date: 10/23/2024
Certification Date: 10/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 N MAIN ST
MANCHESTER CT
06042-2086
US

IV. Provider business mailing address

150 N MAIN ST
MANCHESTER CT
06042-2086
US

V. Phone/Fax

Practice location:
  • Phone: 860-528-1359
  • Fax: 860-291-8990
Mailing address:
  • Phone: 860-528-1359
  • Fax: 860-291-8990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number12.010540
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: