Provider Demographics
NPI:1821150756
Name:GONZALES, PHYLLIS NADINE (DC, BSN-RN)
Entity Type:Individual
Prefix:DR
First Name:PHYLLIS NADINE
Middle Name:
Last Name:GONZALES
Suffix:
Gender:F
Credentials:DC, BSN-RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:121 CAMINO ENCANTADO
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87501-1039
Mailing Address - Country:US
Mailing Address - Phone:505-946-7677
Mailing Address - Fax:505-986-1569
Practice Address - Street 1:219 WASHINGTON AVENUE
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87501-1926
Practice Address - Country:US
Practice Address - Phone:505-946-7677
Practice Address - Fax:505-986-1569
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2015-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1318111NR0400X
CO4766111NR0400X
CADC-29335111NR0400X, 111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM5657319OtherFIRST HEALTH
NM9408737OtherPRIVATE HEALTHCARE SYSTEM
NM12395202OtherMULTIPLAN
NM693017OtherACN GROUP
NMNM00KL98OtherBLUE CROSS BLUE SHIELD NM
OR876338000OtherREGENCE BCBS OREGON