Provider Demographics
NPI:1841388162
Name:GONZALEZ, LUPE AMY (RPT LAC RN)
Entity type:Individual
Prefix:MS
First Name:LUPE
Middle Name:AMY
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:RPT LAC RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1099 BLOOMFIELD AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:WEST CALDWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:07006-7129
Mailing Address - Country:US
Mailing Address - Phone:973-227-7277
Mailing Address - Fax:
Practice Address - Street 1:1099 BLOOMFIELD AVE STE 201
Practice Address - Street 2:
Practice Address - City:WEST CALDWELL
Practice Address - State:NJ
Practice Address - Zip Code:07006
Practice Address - Country:US
Practice Address - Phone:973-227-7277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR06203400163W00000X
NJ40QA00409000225100000X
NJ25MZ00024400171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
643392OtherPTAN