Provider Demographics
NPI:1720685712
Name:GONZALES, BRIANNE NICOLE (PTA)
Entity Type:Individual
Prefix:
First Name:BRIANNE
Middle Name:NICOLE
Last Name:GONZALES
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:740 CAROLIN ST APT 101
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-3262
Mailing Address - Country:US
Mailing Address - Phone:321-213-2282
Mailing Address - Fax:
Practice Address - Street 1:740 CAROLIN ST APT 101
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3262
Practice Address - Country:US
Practice Address - Phone:321-213-2282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-03
Last Update Date:2020-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA30344225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant