Provider Demographics
NPI:1104361096
Name:GONZALIS, CHERYL
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:
Last Name:GONZALIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:859 E MELTON DR.
Mailing Address - Street 2:
Mailing Address - City:JAY
Mailing Address - State:OK
Mailing Address - Zip Code:74346
Mailing Address - Country:US
Mailing Address - Phone:918-253-1759
Mailing Address - Fax:918-253-6822
Practice Address - Street 1:859 E MELTON DR.
Practice Address - Street 2:
Practice Address - City:JAY
Practice Address - State:OK
Practice Address - Zip Code:74346
Practice Address - Country:US
Practice Address - Phone:918-253-1759
Practice Address - Fax:918-253-6822
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-30
Last Update Date:2016-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKL0040074164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse