Provider Demographics
NPI:1689277584
Name:GONZALEZ, MICHELLE GAIL
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:GAIL
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 1:15781 CEDAR GROVE LN
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-6312
Mailing Address - Country:US
Mailing Address - Phone:561-758-2789
Mailing Address - Fax:
Practice Address - Street 1:9990 BELVEDERE RD
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33411-3518
Practice Address - Country:US
Practice Address - Phone:561-795-0135
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-21
Last Update Date:2020-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL27617183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist