Provider Demographics
NPI:1659687580
Name:GONZALES, MARY M (APRN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:M
Last Name:GONZALES
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:M
Other - Last Name:JACOBS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DNP, APRN
Mailing Address - Street 1:PO BOX 1358
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67201-1358
Mailing Address - Country:US
Mailing Address - Phone:316-293-3429
Mailing Address - Fax:316-293-1882
Practice Address - Street 1:1001 N MINNEAPOLIS ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-3127
Practice Address - Country:US
Practice Address - Phone:316-293-1840
Practice Address - Fax:316-293-1866
Is Sole Proprietor?:No
Enumeration Date:2010-08-30
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS53-75195-082363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily