Healthcare Provider Details

I. General information

NPI: 1396354627
Provider Name (Legal Business Name): IBSEN FUNDORA GONZALEZ APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2020
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10095 N KENDALL DR
MIAMI FL
33176-1797
US

IV. Provider business mailing address

11270 PINES BLVD
PEMBROKE PINES FL
33026-4101
US

V. Phone/Fax

Practice location:
  • Phone: 786-504-0904
  • Fax:
Mailing address:
  • Phone: 561-255-9330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11008252
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN11008252
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: