Healthcare Provider Details

I. General information

NPI: 1477464469
Provider Name (Legal Business Name): LIDICE GONZALEZ GONZALEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2026
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4180 SW 53RD AVE
DAVIE FL
33314-3731
US

IV. Provider business mailing address

1400 NW 12TH AVE
MIAMI FL
33136-1003
US

V. Phone/Fax

Practice location:
  • Phone: 786-382-7232
  • Fax:
Mailing address:
  • Phone: 305-689-5808
  • Fax: 305-689-1175

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11050991
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: