Provider Demographics
NPI:1225530728
Name:GONZALES, SALLY
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:
Last Name:GONZALES
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 1:4527 SENISA SPGS
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78251-3502
Mailing Address - Country:US
Mailing Address - Phone:210-833-8764
Mailing Address - Fax:
Practice Address - Street 1:3201 CHERRY RIDGE
Practice Address - Street 2:D-400
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78230
Practice Address - Country:US
Practice Address - Phone:210-692-0222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-01
Last Update Date:2018-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX200381164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164X00000XNursing Service ProvidersLicensed Vocational NurseGroup - Multi-Specialty