Provider Demographics
NPI:1710590153
Name:GONZALEZ, DOMINIQUE MARILYN
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:MARILYN
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 1:2902 N RIVER CREEK PL
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85745-7019
Mailing Address - Country:US
Mailing Address - Phone:520-784-4120
Mailing Address - Fax:
Practice Address - Street 1:2902 N RIVER CREEK PL
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85745-7019
Practice Address - Country:US
Practice Address - Phone:520-784-4120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-25
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program