Provider Demographics
NPI:1962237362
Name:GONZALES, EBONY SHANTELL
Entity type:Individual
Prefix:
First Name:EBONY
Middle Name:SHANTELL
Last Name:GONZALES
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 1:330 LEVINE RD
Mailing Address - Street 2:
Mailing Address - City:ODENVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35120-3607
Mailing Address - Country:US
Mailing Address - Phone:205-760-0752
Mailing Address - Fax:
Practice Address - Street 1:330 LEVINE RD
Practice Address - Street 2:
Practice Address - City:ODENVILLE
Practice Address - State:AL
Practice Address - Zip Code:35120-3607
Practice Address - Country:US
Practice Address - Phone:205-760-0752
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-05
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL246RP1900X
246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy