Provider Demographics
NPI:1972021582
Name:GONZALES, LOUREN M
Entity Type:Individual
Prefix:
First Name:LOUREN
Middle Name:M
Last Name:GONZALES
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 1:100 NICOLLS RD HSC LEVEL 4 ROOM 120
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-3407
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 NICOLLS RD HSC LEVEL 4 ROOM 120
Practice Address - Street 2:HSC LEVEL 4 ROOM 120
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790
Practice Address - Country:US
Practice Address - Phone:631-444-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-04
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY307459363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health