Provider Demographics
NPI:1073918157
Name:GONZALEZ, JULISSA (ARNP)
Entity Type:Individual
Prefix:
First Name:JULISSA
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8381 RIVERWALK PARK BLVD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-8760
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8381 RIVERWALK PARK BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-8760
Practice Address - Country:US
Practice Address - Phone:239-689-5561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-30
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 9261220363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics