Provider Demographics
NPI:1013452192
Name:GONZALEZ, SHERYL (NP-C)
Entity Type:Individual
Prefix:
First Name:SHERYL
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6977 PLACEWAY ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-9704
Mailing Address - Country:US
Mailing Address - Phone:517-262-5226
Mailing Address - Fax:
Practice Address - Street 1:3100 COOPER ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-7545
Practice Address - Country:US
Practice Address - Phone:517-780-6157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-28
Last Update Date:2017-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704169668163W00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1013452192Medicaid