Provider Demographics
NPI:1467054932
Name:GONZALEZ- SANCHEZ, ITZMI SAMANTHA
Entity Type:Individual
Prefix:
First Name:ITZMI
Middle Name:SAMANTHA
Last Name:GONZALEZ- SANCHEZ
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 1:750 S PLAZA DR STE 214
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55120-1505
Mailing Address - Country:US
Mailing Address - Phone:651-406-4454
Mailing Address - Fax:
Practice Address - Street 1:750 S PLAZA DR STE 214
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55120-1505
Practice Address - Country:US
Practice Address - Phone:651-406-4454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-10
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227021334225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist