Provider Demographics
NPI:1639833478
Name:GONZAQUE, MICHELLE (LPN)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:
Last Name:GONZAQUE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:642 MACDONALD AVE
Mailing Address - Street 2:
Mailing Address - City:BELLPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11713-1649
Mailing Address - Country:US
Mailing Address - Phone:631-394-5115
Mailing Address - Fax:
Practice Address - Street 1:642 MACDONALD AVE
Practice Address - Street 2:
Practice Address - City:BELLPORT
Practice Address - State:NY
Practice Address - Zip Code:11713-1649
Practice Address - Country:US
Practice Address - Phone:631-394-5115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-27
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY342766-01164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse