Healthcare Provider Details

I. General information

NPI: 1629620398
Provider Name (Legal Business Name): MONIKA DANIELA GONZALEZ KROLL PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2019
Last Update Date: 07/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

512 WAUGHTOWN ST
WINSTON SALEM NC
27127-2236
US

IV. Provider business mailing address

8 RED SAGE CT
DURHAM NC
27703-9644
US

V. Phone/Fax

Practice location:
  • Phone: 336-512-1172
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number0010-09203
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: