Provider Demographics
NPI:1588030373
Name:GONZALES, GREZELRO (FNP-C)
Entity Type:Individual
Prefix:
First Name:GREZELRO
Middle Name:
Last Name:GONZALES
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:840 W BLACKHAWK ST
Mailing Address - Street 2:1811
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60642-2592
Mailing Address - Country:US
Mailing Address - Phone:630-877-2893
Mailing Address - Fax:
Practice Address - Street 1:840 W IRVING PARK RD
Practice Address - Street 2:301
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-3011
Practice Address - Country:US
Practice Address - Phone:773-975-3269
Practice Address - Fax:773-975-3270
Is Sole Proprietor?:No
Enumeration Date:2015-08-15
Last Update Date:2016-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.012989363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily