Provider Demographics
NPI:1275920282
Name:GONZALEZ, EDELMIRA
Entity Type:Individual
Prefix:
First Name:EDELMIRA
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 1:914 MILLENIUM AVE
Mailing Address - Street 2:
Mailing Address - City:MOXEE
Mailing Address - State:WA
Mailing Address - Zip Code:98936-8806
Mailing Address - Country:US
Mailing Address - Phone:509-703-0208
Mailing Address - Fax:
Practice Address - Street 1:914 MILLENIUM AVE
Practice Address - Street 2:
Practice Address - City:MOXEE
Practice Address - State:WA
Practice Address - Zip Code:98936-8806
Practice Address - Country:US
Practice Address - Phone:509-703-0208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-17
Last Update Date:2017-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator