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General NPI Number Information
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NPI Number | 1396354627
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Entity Type | Individual
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Provider Name | IBSEN FUNDORA GONZALEZ APRN
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Gender | Male
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Dates
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Enumeration Date | 07/22/2020
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Last Update Date | 10/15/2025
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Provider Practice Location Address
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Address Line | 11270 PINES BLVD
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City | PEMBROKE PINES
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State | FL
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Zip | 33026-4101
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Country | US
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Telephone | 954-628-5748
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Fax |
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Provider Business Mailing Address
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Address Line | 11270 PINES BLVD
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City | PEMBROKE PINES
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State | FL
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Zip | 33026-4101
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Country | US
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Telephone | 561-255-9330
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | APRN11008252
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | APRN11008252
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License Number State | FL
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