Provider Demographics
NPI:1770019523
Name:GONZALEZ, MELISSA
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:
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 1:1405 PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-3825
Mailing Address - Country:US
Mailing Address - Phone:804-229-9747
Mailing Address - Fax:
Practice Address - Street 1:1011 JOHNSTON WILLIS DR STE 100
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23235-4808
Practice Address - Country:US
Practice Address - Phone:804-330-4990
Practice Address - Fax:804-330-4529
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2021-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024174956363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care