=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790543510
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MRS. CASEY KATHLEEN GONZALES
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/07/2024
-----------------------------------------------------
Last Update Date | 03/07/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3407 FARNHAM CIR
-----------------------------------------------------
City | PEARLAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77584-9814
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-907-3516
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3407 FARNHAM CIR
-----------------------------------------------------
City | PEARLAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77584-9814
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-907-3516
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2100X
-----------------------------------------------------
Taxonomy Name | Acute Care Nurse Practitioner
-----------------------------------------------------
License Number | 1153780
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------