Healthcare Provider Details

I. General information

NPI: 1104636950
Provider Name (Legal Business Name): DARLA IDALIA GONZALEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2025
Last Update Date: 01/13/2025
Certification Date: 01/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 OLD BUSINESS HWY 60
VAN BUREN MO
63965
US

IV. Provider business mailing address

1011 OLD BUSINESS HWY 60
VAN BUREN MO
63965
US

V. Phone/Fax

Practice location:
  • Phone: 573-323-2171
  • Fax:
Mailing address:
  • Phone: 573-323-2171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: