Provider Demographics
NPI:1457776163
Name:GONZALEZ, MICHELLE MARGUERITE (APRN)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MARGUERITE
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:MARGUERITE
Other - Last Name:PANCHAK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:APRN
Mailing Address - Street 1:18 CLEARVIEW DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06074-2230
Mailing Address - Country:US
Mailing Address - Phone:860-593-4630
Mailing Address - Fax:
Practice Address - Street 1:18 CLEARVIEW DR
Practice Address - Street 2:
Practice Address - City:SOUTH WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06074-2230
Practice Address - Country:US
Practice Address - Phone:860-843-2012
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-04
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT005680363L00000X, 363LA2200X, 363LG0600X
CT5680363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health