Basic Information
| Provider Information | |||||||||
| NPI: | 1144522996 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GONZALEZ | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | FNP-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PROSSER | ||||||||
| OtherFirstName: | JESSICA | ||||||||
| OtherMiddleName: | ANNE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 571 SAINT JOSEPHS BLVD | ||||||||
| Address2: | FL 2 | ||||||||
| City: | ELMIRA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 149013230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6072712050 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 200 MADISON AVE | ||||||||
| Address2: | SUITE 2D | ||||||||
| City: | ELMIRA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 149013218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077334681 | ||||||||
| FaxNumber: | 6077331729 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2010 | ||||||||
| LastUpdateDate: | 06/10/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | F336277-1 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 336277 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 03316305 | 05 | NY | MEDICAID |