MEDICARE: ALICE MARIE GONZALES RN

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	163WE0003X	Emergency Registered Nurse	RN045395	AZ

General Provider Information

NPI Number	:	1306977327
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALICE MARIE GONZALES RN

Provider Business Mailing Address
First Line	:	3115 KIOWA BLVD N
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86404-1501
Country	:	US
Telephone Number	:	928-812-1308
Fax Number	:

Provider Business Practice Location Address
First Line	:	3115 KIOWA BLVD N
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86404-1501
Country	:	US
Telephone Number	:	928-812-1308
Fax Number	:

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

Provider Enumeration Date	:	03/08/2007
Last Update Date	:	07/08/2007

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