Provider Demographics
NPI:1508273848
Name:GONZALES, NICOLE R (CNM)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:R
Last Name:GONZALES
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:RENEE
Other - Last Name:PERON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNM
Mailing Address - Street 1:1661 E CAMELBACK RD STE 200
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-3913
Mailing Address - Country:US
Mailing Address - Phone:602-422-9000
Mailing Address - Fax:602-556-5951
Practice Address - Street 1:35 N ESTRELLA PKWY
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-4690
Practice Address - Country:US
Practice Address - Phone:623-846-7558
Practice Address - Fax:623-846-1674
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-18
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN186831163WS0200X
AZTEMP267062367A00000X
AZ267062367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No163WS0200XNursing Service ProvidersRegistered NurseSchool