Healthcare Provider Details

I. General information

NPI: 1982933974
Provider Name (Legal Business Name): JENNIFER L GONZALEZ APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2009
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E PENNSYLVANIA AVE
PEORIA IL
61603-3089
US

IV. Provider business mailing address

1001 MAIN ST STE 400
PEORIA IL
61606-2036
US

V. Phone/Fax

Practice location:
  • Phone: 309-655-2045
  • Fax: 309-655-2057
Mailing address:
  • Phone: 309-308-0920
  • Fax: 309-308-0930

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041309807
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209-008074
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number209-003998
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: