Healthcare Provider Details

I. General information

NPI: 1821150756
Provider Name (Legal Business Name): PHYLLIS NADINE GONZALES DC, BSN-RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2006
Last Update Date: 03/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

219 WASHINGTON AVENUE
SANTA FE NM
87501-1926
US

IV. Provider business mailing address

121 CAMINO ENCANTADO
SANTA FE NM
87501-1039
US

V. Phone/Fax

Practice location:
  • Phone: 505-946-7677
  • Fax: 505-986-1569
Mailing address:
  • Phone: 505-946-7677
  • Fax: 505-986-1569

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number1318
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number4766
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License NumberDC-29335
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: