Healthcare Provider Details

I. General information

NPI: 1730709866
Provider Name (Legal Business Name): MICHELLE GONZALEZ LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MICHELLE GONZALEZ LPN

II. Dates (important events)

Enumeration Date: 04/18/2020
Last Update Date: 05/12/2023
Certification Date: 05/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7906 N 39TH ST
AUGUSTA MI
49012-9714
US

IV. Provider business mailing address

7906 N 39TH ST
AUGUSTA MI
49012-9714
US

V. Phone/Fax

Practice location:
  • Phone: 734-812-6973
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number4704228622
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: