Provider Demographics
NPI:1518536440
Name:GONZALES, BENITA (LPN)
Entity Type:Individual
Prefix:
First Name:BENITA
Middle Name:
Last Name:GONZALES
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:BENITS
Other - Middle Name:
Other - Last Name:DECATUR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPN
Mailing Address - Street 1:308 S MOUNTAIN ST
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48706-4253
Mailing Address - Country:US
Mailing Address - Phone:989-930-7522
Mailing Address - Fax:
Practice Address - Street 1:308 S MOUNTAIN ST
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48706-4253
Practice Address - Country:US
Practice Address - Phone:989-930-7522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-24
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703081394164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse