Provider Demographics
NPI:1659877538
Name:GONZAGA, JASMINE MALEY
Entity Type:Individual
Prefix:MRS
First Name:JASMINE
Middle Name:MALEY
Last Name:GONZAGA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JASMINE
Other - Middle Name:MALEY
Other - Last Name:GONZAGA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:943 TETON AVE
Mailing Address - Street 2:
Mailing Address - City:SHELBY
Mailing Address - State:MT
Mailing Address - Zip Code:59474-1526
Mailing Address - Country:US
Mailing Address - Phone:408-477-6523
Mailing Address - Fax:
Practice Address - Street 1:943 TETON AVE
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:MT
Practice Address - Zip Code:59474-1526
Practice Address - Country:US
Practice Address - Phone:408-477-6523
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-01
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV110403163W00000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse