Provider Demographics
NPI:1528605284
Name:GONZALES, ELISA MARIA (MS, RD, LD)
Entity Type:Individual
Prefix:
First Name:ELISA
Middle Name:MARIA
Last Name:GONZALES
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:646 S FLORES ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78204-1219
Mailing Address - Country:US
Mailing Address - Phone:855-481-1149
Mailing Address - Fax:
Practice Address - Street 1:10718 POTRANCO RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78251-3312
Practice Address - Country:US
Practice Address - Phone:855-481-1149
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-02
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT83501133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist