Provider Demographics
NPI:1053090647
Name:GONZALEZ, DANIELA RAE
Entity type:Individual
Prefix:
First Name:DANIELA
Middle Name:RAE
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 1:1042 DEFORREST ST
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78404-2739
Mailing Address - Country:US
Mailing Address - Phone:361-429-0143
Mailing Address - Fax:
Practice Address - Street 1:15406 NORTHWEST BLVD STE B
Practice Address - Street 2:
Practice Address - City:ROBSTOWN
Practice Address - State:TX
Practice Address - Zip Code:78380-5865
Practice Address - Country:US
Practice Address - Phone:361-232-4187
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-12
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1128339363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily