Provider Demographics
NPI:1801362405
Name:GONZALEZ, BRYANA JUSITNE
Entity Type:Individual
Prefix:
First Name:BRYANA
Middle Name:JUSITNE
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 1:910 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:ALICE
Mailing Address - State:TX
Mailing Address - Zip Code:78332-3913
Mailing Address - Country:US
Mailing Address - Phone:361-944-8241
Mailing Address - Fax:
Practice Address - Street 1:4444 CORONA DR STE 107
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78411-4374
Practice Address - Country:US
Practice Address - Phone:361-400-1886
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-22
Last Update Date:2018-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX339143164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse