Provider Demographics
NPI:1831871805
Name:GONZALEZ, MALISSIA ELLEN (FNP)
Entity type:Individual
Prefix:
First Name:MALISSIA
Middle Name:ELLEN
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5105 PAULSEN ST STE 241B
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405-4622
Mailing Address - Country:US
Mailing Address - Phone:912-335-7712
Mailing Address - Fax:
Practice Address - Street 1:5105 PAULSEN ST STE 241B
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-4622
Practice Address - Country:US
Practice Address - Phone:912-335-7712
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-01
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN272396363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily