Provider Demographics
NPI:1255749115
Name:GONZALEZ, BECKY (CNP)
Entity type:Individual
Prefix:
First Name:BECKY
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4504 4TH ST NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107-3956
Mailing Address - Country:US
Mailing Address - Phone:505-433-4493
Mailing Address - Fax:505-433-5271
Practice Address - Street 1:3911 4TH ST NW STE B
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-2510
Practice Address - Country:US
Practice Address - Phone:505-433-4493
Practice Address - Fax:505-433-5271
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-23
Last Update Date:2018-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP-02477363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1255749115OtherNPI
NM91906563Medicaid