MEDICARE: MRS. KELLY LYNN GONZALEZ

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	376K00000X	Nurse's Aide	400572081206	OH

General Provider Information

NPI Number	:	1285784611
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KELLY LYNN GONZALEZ

Provider Business Mailing Address
First Line	:	1143 S ELM ST
Second Line	:
City	:	WASHINGTON COURT HOUSE
State	:	OH
Zip	:	43160-2027
Country	:	US
Telephone Number	:	740-463-3413
Fax Number	:

Provider Business Practice Location Address
First Line	:	1143 S ELM ST
Second Line	:
City	:	WASHINGTON COURT HOUSE
State	:	OH
Zip	:	43160-2027
Country	:	US
Telephone Number	:	740-463-3413
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/10/2007
Last Update Date	:	07/08/2007

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