Provider Demographics
NPI:1649988650
Name:GONZALEZ, LISSETTE MARIE (MSN, AGACNP-BC)
Entity type:Individual
Prefix:MRS
First Name:LISSETTE
Middle Name:MARIE
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:MSN, AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4321 SW 160TH AVE APT 104
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33027-5763
Mailing Address - Country:US
Mailing Address - Phone:954-604-5144
Mailing Address - Fax:
Practice Address - Street 1:4321 SW 160TH AVE APT 104
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33027-5763
Practice Address - Country:US
Practice Address - Phone:954-604-5144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-08
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11022678363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Single Specialty