Provider Demographics
NPI:1356670939
Name:GONZALEZ, LISSA L (CRNP)
Entity Type:Individual
Prefix:
First Name:LISSA
Middle Name:L
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2585 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25703-1642
Mailing Address - Country:US
Mailing Address - Phone:304-697-1396
Mailing Address - Fax:304-697-2086
Practice Address - Street 1:6350 US ROUTE 60 E
Practice Address - Street 2:
Practice Address - City:BARBOURSVILLE
Practice Address - State:WV
Practice Address - Zip Code:25504
Practice Address - Country:US
Practice Address - Phone:304-399-3350
Practice Address - Fax:304-955-5047
Is Sole Proprietor?:No
Enumeration Date:2009-12-10
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVAPRN67319363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810023589Medicaid
WV3810023589Medicaid
WVWV1643AMedicare PIN
WVWV1643DMedicare PIN
WVWV1643CMedicare PIN