Provider Demographics
NPI:1114435732
Name:GONZALEZ, IRAIDA
Entity Type:Individual
Prefix:
First Name:IRAIDA
Middle Name:
Last Name:GONZALEZ
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 1:3642 BOULDER HWY TRLR 163
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89121-1634
Mailing Address - Country:US
Mailing Address - Phone:702-690-8056
Mailing Address - Fax:
Practice Address - Street 1:2860 E FLAMINGO RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-5271
Practice Address - Country:US
Practice Address - Phone:702-318-5005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-17
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No372500000XNursing Service Related ProvidersChore Provider
No372600000XNursing Service Related ProvidersAdult Companion
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
No376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
2104808131OtherDRIVERS LISCENCE