Provider Demographics
NPI:1649041740
Name:JUSTINIANO GONZALES, RAQUEL ((LM)LICENSED MIDWIFE)
Entity type:Individual
Prefix:
First Name:RAQUEL
Middle Name:
Last Name:JUSTINIANO GONZALES
Suffix:
Gender:F
Credentials:(LM)LICENSED MIDWIFE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1440 SMOKE HILL DR
Mailing Address - Street 2:
Mailing Address - City:HOSCHTON
Mailing Address - State:GA
Mailing Address - Zip Code:30548-1752
Mailing Address - Country:US
Mailing Address - Phone:423-661-9226
Mailing Address - Fax:
Practice Address - Street 1:951 N WASHINGTON AVE BLDG 4
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32796-2194
Practice Address - Country:US
Practice Address - Phone:321-268-6111
Practice Address - Fax:321-268-6364
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-09
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTMW20176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife