Healthcare Provider Details

I. General information

NPI: 1194447318
Provider Name (Legal Business Name): JENNIFER GONZALEZ APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2022
Last Update Date: 02/22/2024
Certification Date: 02/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1455 E PUTNAM AVE STE 1
OLD GREENWICH CT
06870-1360
US

IV. Provider business mailing address

1455 E PUTNAM AVE STE 1
OLD GREENWICH CT
06870-1360
US

V. Phone/Fax

Practice location:
  • Phone: 203-637-3337
  • Fax: 203-637-3307
Mailing address:
  • Phone: 203-637-3337
  • Fax: 203-637-3307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number10988
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: