=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750614376
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARIAELENA GONZALEZ FNP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2009
-----------------------------------------------------
Last Update Date | 09/11/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 103 LIVINGSTON LOOP STE B4
-----------------------------------------------------
City | SANTA TERESA
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88008-9747
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 915-888-9115
-----------------------------------------------------
Fax | 915-995-4972
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 103 LIVINGSTON LOOP STE B4
-----------------------------------------------------
City | SANTA TERESA
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88008-9747
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 915-888-9115
-----------------------------------------------------
Fax | 915-995-4972
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | CNP-02301
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 678490
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------