Healthcare Provider Details

I. General information

NPI: 1831005180
Provider Name (Legal Business Name): CLARISSA ELIZABETH GONZALEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2026
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 HEALTH PARK BLVD
SAINT AUGUSTINE FL
32086-5784
US

IV. Provider business mailing address

1205 WILDFAIR CT
SAINT AUGUSTINE FL
32092-0404
US

V. Phone/Fax

Practice location:
  • Phone: 904-244-5029
  • Fax:
Mailing address:
  • Phone: 828-316-1845
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code243U00000X
TaxonomyRadiology Practitioner Assistant
License NumberRA136
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: