Provider Demographics
NPI:1013461425
Name:THOMAS, MARITESS GONZALES (FNP-C)
Entity Type:Individual
Prefix:
First Name:MARITESS
Middle Name:GONZALES
Last Name:THOMAS
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:MARITESS
Other - Middle Name:GONZALES
Other - Last Name:THOMAS-FORD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1058 BEAR CREEK BLVD
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:GA
Mailing Address - Zip Code:30228-1849
Mailing Address - Country:US
Mailing Address - Phone:770-707-0808
Mailing Address - Fax:770-707-1580
Practice Address - Street 1:3800 PRINCETON LAKES PKWY SW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30331-5580
Practice Address - Country:US
Practice Address - Phone:404-948-3019
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-15
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN161969363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily