Provider Demographics
NPI:1326607979
Name:GONZALEZ, PAULEENA (RN)
Entity Type:Individual
Prefix:
First Name:PAULEENA
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 SWALLOW LN
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717-1341
Mailing Address - Country:US
Mailing Address - Phone:631-398-0364
Mailing Address - Fax:
Practice Address - Street 1:12 JAY CT
Practice Address - Street 2:
Practice Address - City:BOHEMIA
Practice Address - State:NY
Practice Address - Zip Code:11716-3816
Practice Address - Country:US
Practice Address - Phone:631-355-6722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-07
Last Update Date:2019-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY753143163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYEN73431YMedicaid