Provider Demographics
NPI:1063178549
Name:GONZALEZ, AMANDA NICOLE
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:NICOLE
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:138 AGENCY OAKS
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78249-1538
Mailing Address - Country:US
Mailing Address - Phone:830-421-0137
Mailing Address - Fax:
Practice Address - Street 1:12125 ALAMO RANCH PKWY
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78253-4334
Practice Address - Country:US
Practice Address - Phone:210-688-9584
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-09
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX28598183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician