Provider Demographics
NPI:1376524967
Name:GONZALES, CARYN SUE (ANP)
Entity Type:Individual
Prefix:MS
First Name:CARYN
Middle Name:SUE
Last Name:GONZALES
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2649
Mailing Address - Street 2:
Mailing Address - City:PALMER
Mailing Address - State:AK
Mailing Address - Zip Code:99645-2649
Mailing Address - Country:US
Mailing Address - Phone:907-631-3684
Mailing Address - Fax:907-707-1212
Practice Address - Street 1:16720 E MAUD RD
Practice Address - Street 2:
Practice Address - City:PALMER
Practice Address - State:AK
Practice Address - Zip Code:99645-7520
Practice Address - Country:US
Practice Address - Phone:907-631-3684
Practice Address - Fax:907-707-1212
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-10
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK858363LP0808X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1022580Medicaid