Provider Demographics
NPI:1487363339
Name:MAVROS GONZALEZ, MARIANTY (NP)
Entity type:Individual
Prefix:MS
First Name:MARIANTY
Middle Name:
Last Name:MAVROS GONZALEZ
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 W BIG BEAVER RD STE 300
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-4725
Mailing Address - Country:US
Mailing Address - Phone:910-556-9645
Mailing Address - Fax:248-294-1150
Practice Address - Street 1:801 W BIG BEAVER RD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-4726
Practice Address - Country:US
Practice Address - Phone:781-725-6586
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-18
Last Update Date:2025-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2212111333163W00000X
MARN2364616363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse