Provider Demographics
NPI:1790254571
Name:GONZALEZ, STEPHANIE YASMIN
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:YASMIN
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:HC 4 BOX 43575
Mailing Address - Street 2:
Mailing Address - City:LARES
Mailing Address - State:PR
Mailing Address - Zip Code:00669-9431
Mailing Address - Country:US
Mailing Address - Phone:787-453-3142
Mailing Address - Fax:
Practice Address - Street 1:HC 4 BOX 43575
Practice Address - Street 2:
Practice Address - City:LARES
Practice Address - State:PR
Practice Address - Zip Code:00669-9431
Practice Address - Country:US
Practice Address - Phone:787-453-3142
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-21
Last Update Date:2018-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
011567183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR6163993OtherLICENSE NUMBER