Healthcare Provider Details

I. General information

NPI: 1326865395
Provider Name (Legal Business Name): CAMILLE GONZALES PMHNP-BC, MSN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2024
Last Update Date: 08/28/2026
Certification Date: 08/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

171 COUNTRY CLUB DR UNIT 5
UNION NJ
07083-8747
US

IV. Provider business mailing address

171 COUNTRY CLUB DR UNIT 5
UNION NJ
07083-8747
US

V. Phone/Fax

Practice location:
  • Phone: 516-445-9122
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number26NR24154800
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number409102
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: