Provider Demographics
NPI:1790543494
Name:GONZALEZ, MELISSA VALENTINA
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:VALENTINA
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:VALENTINA
Other - Last Name:GONZALEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:869 W BUENA AVE APT 607
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-1660
Mailing Address - Country:US
Mailing Address - Phone:773-936-1113
Mailing Address - Fax:
Practice Address - Street 1:1859 W DIVERSEY PKWY
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-1011
Practice Address - Country:US
Practice Address - Phone:773-936-1113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-08
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherGroup - Single Specialty