Provider Demographics
NPI:1659697878
Name:GONZALES, CHARMAINE JACKQULIN (ANP)
Entity type:Individual
Prefix:
First Name:CHARMAINE
Middle Name:JACKQULIN
Last Name:GONZALES
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:CHARMAINE
Other - Middle Name:JACKQULIN
Other - Last Name:MORGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 746087
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6087
Mailing Address - Country:US
Mailing Address - Phone:312-733-9730
Mailing Address - Fax:
Practice Address - Street 1:8923 FLATLANDS AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11236-3613
Practice Address - Country:US
Practice Address - Phone:718-765-6000
Practice Address - Fax:347-436-9621
Is Sole Proprietor?:No
Enumeration Date:2010-04-13
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY305324363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health