Provider Demographics
NPI:1457962300
Name:GONZALEZ ACOSTA, SUSEL LILIANA
Entity Type:Individual
Prefix:
First Name:SUSEL
Middle Name:LILIANA
Last Name:GONZALEZ ACOSTA
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 1:4510 SW 5TH ST
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33134-1918
Mailing Address - Country:US
Mailing Address - Phone:786-747-2115
Mailing Address - Fax:
Practice Address - Street 1:4510 SW 5TH ST
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33134-1918
Practice Address - Country:US
Practice Address - Phone:786-747-2115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-13
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11008465363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
11008465Other11008465