Provider Demographics
NPI:1083946768
Name:GONZALES, ALICIA LEANDRA (LMP)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:LEANDRA
Last Name:GONZALES
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5450-102 CUDA LANE SW
Mailing Address - Street 2:
Mailing Address - City:TUMWATER
Mailing Address - State:WA
Mailing Address - Zip Code:98512
Mailing Address - Country:US
Mailing Address - Phone:360-349-3979
Mailing Address - Fax:
Practice Address - Street 1:5450 CUDA LN UNIT 102
Practice Address - Street 2:
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98512-6942
Practice Address - Country:US
Practice Address - Phone:360-349-3979
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-05
Last Update Date:2010-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60109727174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist