Healthcare Provider Details

I. General information

NPI: 1104206895
Provider Name (Legal Business Name): NICOLE ELIZABETH GONZALEZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2015
Last Update Date: 03/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2055 KIMBALL AVE SUITE 101
WATERLOO IA
50702-5047
US

IV. Provider business mailing address

5410 MARYLAND WAY STE 300
BRENTWOOD TN
37027-5339
US

V. Phone/Fax

Practice location:
  • Phone: 319-272-2112
  • Fax: 319-272-2107
Mailing address:
  • Phone: 615-371-4423
  • Fax: 319-272-2107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR-10211
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number56116
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: