Provider Demographics
NPI:1285784611
Name:GONZALEZ, KELLY LYNN
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:LYNN
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:DANIELS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1143 S ELM ST
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON COURT HOUSE
Mailing Address - State:OH
Mailing Address - Zip Code:43160-2027
Mailing Address - Country:US
Mailing Address - Phone:740-463-3413
Mailing Address - Fax:
Practice Address - Street 1:1143 S ELM ST
Practice Address - Street 2:
Practice Address - City:WASHINGTON COURT HOUSE
Practice Address - State:OH
Practice Address - Zip Code:43160-2027
Practice Address - Country:US
Practice Address - Phone:740-463-3413
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH400572081206376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide