Provider Demographics
NPI:1255923157
Name:GONZALEZ LOPEZ, NOEMI
Entity type:Individual
Prefix:
First Name:NOEMI
Middle Name:
Last Name:GONZALEZ LOPEZ
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:HC 4 BOX 46891
Mailing Address - Street 2:
Mailing Address - City:MAYAGUEZ
Mailing Address - State:PR
Mailing Address - Zip Code:00680-9426
Mailing Address - Country:US
Mailing Address - Phone:787-944-6805
Mailing Address - Fax:
Practice Address - Street 1:CARR 353 KM 1.0 INT CAMINO LOS BORRERO
Practice Address - Street 2:
Practice Address - City:MAYAGUEZ
Practice Address - State:PR
Practice Address - Zip Code:00680-9426
Practice Address - Country:US
Practice Address - Phone:787-944-6805
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-11
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR1986086OtherADMINISTRATION