=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376134759
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROSA MARITZA GONZALEZ DRIVER LICENSES
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/28/2021
-----------------------------------------------------
Last Update Date | 01/28/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5276 NE 6TH AVE APT 19G
-----------------------------------------------------
City | OAKLAND PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33334-3329
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 754-235-6254
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5276 NE 6TH AVE APT. 19 G
-----------------------------------------------------
City | OAKLAND PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33334
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 754-235-6254
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | MA85668
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------