Healthcare Provider Details

I. General information

NPI: 1689393019
Provider Name (Legal Business Name): IBIS E GONZALEZ APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: IBIS E ECHEMENDIA APRN

II. Dates (important events)

Enumeration Date: 08/29/2022
Last Update Date: 04/08/2024
Certification Date: 04/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 W SR 434
LONGWOOD FL
32750-5119
US

IV. Provider business mailing address

555 W SR 434
LONGWOOD FL
32750-5119
US

V. Phone/Fax

Practice location:
  • Phone: 407-767-1200
  • Fax:
Mailing address:
  • Phone: 321-842-2994
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAPRN11021537
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAPRN11021537
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: