Provider Demographics
NPI:1669015921
Name:GONZALEZ, ROSA NICOLE
Entity Type:Individual
Prefix:
First Name:ROSA
Middle Name:NICOLE
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10110 FOX RUN CT
Mailing Address - Street 2:
Mailing Address - City:STREETSBORO
Mailing Address - State:OH
Mailing Address - Zip Code:44241-4335
Mailing Address - Country:US
Mailing Address - Phone:216-526-9958
Mailing Address - Fax:
Practice Address - Street 1:9500 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44195-4335
Practice Address - Country:US
Practice Address - Phone:216-526-9958
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-18
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.007200363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program