Healthcare Provider Details

I. General information

NPI: 1689160756
Provider Name (Legal Business Name): JESSICA GONZALEZ FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2018
Last Update Date: 07/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

435 SAINT MICHAELS DR STE 101
SANTA FE NM
87505-7672
US

IV. Provider business mailing address

2623 VIA BERRENDA
SANTA FE NM
87505-6731
US

V. Phone/Fax

Practice location:
  • Phone: 505-982-5504
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP-03609
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: