Provider Demographics
NPI:1770964504
Name:GOUGH, MICHELLE (RN, MSN, FNP-C)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:GOUGH
Suffix:
Gender:F
Credentials:RN, MSN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15055 LOS GATOS BLVD
Mailing Address - Street 2:STE 250
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95032-2083
Mailing Address - Country:US
Mailing Address - Phone:408-418-0808
Mailing Address - Fax:408-520-4960
Practice Address - Street 1:15055 LOS GATOS BLVD
Practice Address - Street 2:STE 250
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95032-2083
Practice Address - Country:US
Practice Address - Phone:408-418-0808
Practice Address - Fax:408-520-4960
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-17
Last Update Date:2015-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95000661363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily