Basic Information
| Provider Information | |||||||||
| NPI: | 1104206895 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GONZALEZ | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5410 MARYLAND WAY STE 300 | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370275339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153714423 | ||||||||
| FaxNumber: | 3192722107 | ||||||||
| Practice Location | |||||||||
| Address1: | 2055 KIMBALL AVE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | WATERLOO | ||||||||
| State: | IA | ||||||||
| PostalCode: | 507025047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3192722112 | ||||||||
| FaxNumber: | 3192722107 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2015 | ||||||||
| LastUpdateDate: | 03/25/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | R-10211 | IA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 56116 | AZ | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.