Provider Demographics
NPI:1689317166
Name:GONZALES, ELOISE MARIA (APRN)
Entity Type:Individual
Prefix:
First Name:ELOISE
Middle Name:MARIA
Last Name:GONZALES
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 508
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06141-0508
Mailing Address - Country:US
Mailing Address - Phone:860-680-3120
Mailing Address - Fax:
Practice Address - Street 1:324 ELM ST STE 202B
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:CT
Practice Address - Zip Code:06468-2284
Practice Address - Country:US
Practice Address - Phone:203-880-5335
Practice Address - Fax:860-675-2155
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-14
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT12.010540363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner