Provider Demographics
NPI:1003367194
Name:GONZALES, STEPHANIE (CPHT)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:GONZALES
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3227 EL TOBOSO DR NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87104-3059
Mailing Address - Country:US
Mailing Address - Phone:505-252-7452
Mailing Address - Fax:
Practice Address - Street 1:3227 EL TOBOSO DR NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87104-3059
Practice Address - Country:US
Practice Address - Phone:505-252-7452
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-24
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPT00001723183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician