Provider Demographics
NPI:1528624970
Name:GONZALES, LISA (RN, IBCLC)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:
Last Name:GONZALES
Suffix:
Gender:F
Credentials:RN, IBCLC
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:MYERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:32050 SW WILLAMETTE WAY E
Mailing Address - Street 2:
Mailing Address - City:WILSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97070-9596
Mailing Address - Country:US
Mailing Address - Phone:503-939-6243
Mailing Address - Fax:
Practice Address - Street 1:32050 SW WILLAMETTE WAY E
Practice Address - Street 2:
Practice Address - City:WILSONVILLE
Practice Address - State:OR
Practice Address - Zip Code:97070-9596
Practice Address - Country:US
Practice Address - Phone:503-939-6243
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-11
Last Update Date:2019-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201143372RN163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant