Provider Demographics
NPI:1720563166
Name:GONZALES, AMBER LEE
Entity Type:Individual
Prefix:
First Name:AMBER LEE
Middle Name:
Last Name:GONZALES
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 1:3504 KAYENTA DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87402-5232
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:701 MCCORMICK SCHOOL RD
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-7141
Practice Address - Country:US
Practice Address - Phone:505-599-8606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-02
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRN-79452163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool