Provider Demographics
NPI:1457758179
Name:SUBRAMANI GONZALEZ, SHIVANNA (DNP)
Entity Type:Individual
Prefix:
First Name:SHIVANNA
Middle Name:
Last Name:SUBRAMANI GONZALEZ
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:SHIVANNA
Other - Middle Name:
Other - Last Name:SUBRAMANI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:504 WOLCOTT RD STE C
Mailing Address - Street 2:
Mailing Address - City:WOLCOTT
Mailing Address - State:CT
Mailing Address - Zip Code:06716-2462
Mailing Address - Country:US
Mailing Address - Phone:860-714-2913
Mailing Address - Fax:860-714-8988
Practice Address - Street 1:504 WOLCOTT RD
Practice Address - Street 2:
Practice Address - City:WOLCOTT
Practice Address - State:CT
Practice Address - Zip Code:06716-2461
Practice Address - Country:US
Practice Address - Phone:203-725-5339
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-24
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5993363LF0000X, 363LP2300X
CT009553363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT005993OtherSTATE LICENSE