Provider Demographics
NPI:1033793641
Name:WAUNA, MARIE ROCHELLE GONZALO
Entity Type:Individual
Prefix:
First Name:MARIE ROCHELLE
Middle Name:GONZALO
Last Name:WAUNA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARIE ROCHELLE
Other - Middle Name:CASIMIRO
Other - Last Name:GONZALO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:40 75TH ST
Mailing Address - Street 2:
Mailing Address - City:WILLOWBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60527-2325
Mailing Address - Country:US
Mailing Address - Phone:630-581-5372
Mailing Address - Fax:
Practice Address - Street 1:40 75TH ST
Practice Address - Street 2:
Practice Address - City:WILLOWBROOK
Practice Address - State:IL
Practice Address - Zip Code:60527-2325
Practice Address - Country:US
Practice Address - Phone:630-581-5372
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-10
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209023173363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner