Provider Demographics
NPI:1194394155
Name:GONZALEZ, CHRISTINA NICOLE
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:NICOLE
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 1:13605 GRANGER AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32827-7264
Mailing Address - Country:US
Mailing Address - Phone:954-298-4493
Mailing Address - Fax:
Practice Address - Street 1:13605 GRANGER AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32827-7264
Practice Address - Country:US
Practice Address - Phone:954-298-4493
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-23
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSI4903261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center