Healthcare Provider Details

I. General information

NPI: 1659968618
Provider Name (Legal Business Name): KARIS GONSALVES RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/24/2020
Last Update Date: 07/09/2022
Certification Date: 02/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2665 N DECATUR RD
DECATUR GA
30033-6149
US

IV. Provider business mailing address

2665 N DECATUR RD
DECATUR GA
30033-6149
US

V. Phone/Fax

Practice location:
  • Phone: 516-253-1649
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0600X
TaxonomyGerontology Registered Nurse
License NumberRN244438
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberRN244438
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: