Provider Demographics
NPI:1457506677
Name:GONZALEZ, SUSAN (CNP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4100 E 27TH ST
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55406-1804
Mailing Address - Country:US
Mailing Address - Phone:612-216-8640
Mailing Address - Fax:
Practice Address - Street 1:2550 UNIVERSITY AVE W STE 229N
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114-1902
Practice Address - Country:US
Practice Address - Phone:651-645-3115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-02
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1088363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5008775780OtherBCBSMI
MI5008775780OtherBCBSMI