Provider Demographics
NPI:1780147470
Name:GONZALEZ, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 N WHITE OAK RD LOT B5
Mailing Address - Street 2:
Mailing Address - City:WHITE OAK
Mailing Address - State:TX
Mailing Address - Zip Code:75693-2565
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:700 N WHITE OAK RD LOT B5
Practice Address - Street 2:
Practice Address - City:WHITE OAK
Practice Address - State:TX
Practice Address - Zip Code:75693-2565
Practice Address - Country:US
Practice Address - Phone:903-240-1363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-09
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX329538164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse