Basic Information
| Provider Information | |||||||||
| NPI: | 1073548731 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GONZALEZ | ||||||||
| FirstName: | YOLANDA | ||||||||
| MiddleName: | Y | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RNC NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ZEPEDA | ||||||||
| OtherFirstName: | YOLANDA | ||||||||
| OtherMiddleName: | Y | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 4699 | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479034699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654492732 | ||||||||
| FaxNumber: | 7654465317 | ||||||||
| Practice Location | |||||||||
| Address1: | 975 MEZZANINE DR | ||||||||
| Address2: | SUITE C | ||||||||
| City: | LAFAYETTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479058635 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7658072780 | ||||||||
| FaxNumber: | 7658072781 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 12/14/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LW0102X | 71001963A | IN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health | 363L00000X | 71001963A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 200529640 | 05 | IN | MEDICAID | 71001963A | 01 | IN | STATE LICENSE | OTHER |