Provider Demographics
NPI:1447613732
Name:GONZALES, NYKIA
Entity Type:Individual
Prefix:
First Name:NYKIA
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 1:2511 MEMORIAL AVE
Mailing Address - Street 2:SUITE 302
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24501-2657
Mailing Address - Country:US
Mailing Address - Phone:434-515-2770
Mailing Address - Fax:
Practice Address - Street 1:2511 MEMORIAL AVE
Practice Address - Street 2:SUITE 302
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-2657
Practice Address - Country:US
Practice Address - Phone:434-515-2770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-04
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA251172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver