MEDICARE: MELISSA VALENTINA 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	246Z00000X	Other Specialist/Technologist

General Provider Information

NPI Number	:	1790543494
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELISSA VALENTINA GONZALEZ

Provider Business Mailing Address
First Line	:	869 W BUENA AVE APT 607
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-1660
Country	:	US
Telephone Number	:	773-936-1113
Fax Number	:

Provider Business Practice Location Address
First Line	:	1859 W DIVERSEY PKWY
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-1011
Country	:	US
Telephone Number	:	773-936-1113
Fax Number	:

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

Provider Enumeration Date	:	03/08/2024
Last Update Date	:	03/08/2024

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