Healthcare Provider Details

I. General information

NPI: 1588030373
Provider Name (Legal Business Name): GREZELRO GONZALES FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2015
Last Update Date: 04/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 W IRVING PARK RD 301
CHICAGO IL
60613-3011
US

IV. Provider business mailing address

840 W BLACKHAWK ST 1811
CHICAGO IL
60642-2592
US

V. Phone/Fax

Practice location:
  • Phone: 773-975-3269
  • Fax: 773-975-3270
Mailing address:
  • Phone: 630-877-2893
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.012989
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: