Provider Demographics
NPI:1568523835
Name:GONZALES, MICHELE AIDA DOMINQUE (CNM)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:AIDA DOMINQUE
Last Name:GONZALES
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:MICHELE
Other - Middle Name:
Other - Last Name:GONZALES-SHEENAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:900 E HAMILTON AVE
Mailing Address - Street 2:STE 220
Mailing Address - City:CAMPBELL
Mailing Address - State:CA
Mailing Address - Zip Code:95008-0664
Mailing Address - Country:US
Mailing Address - Phone:408-371-7111
Mailing Address - Fax:
Practice Address - Street 1:900 EAST HAMILTON AVE
Practice Address - Street 2:STE 220
Practice Address - City:CAMPBELL
Practice Address - State:CA
Practice Address - Zip Code:95008
Practice Address - Country:US
Practice Address - Phone:408-371-7111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANMW1038367A00000X
CARN443870363L00000X, 363LP1700X
CA7189367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP1700XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPerinatal
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARN443870Medicaid
CAQ45397Medicare UPIN