Provider Demographics
NPI:1689317166
Name:GONZALES, ELOISE MARIA (APRN)
Entity type:Individual
Prefix:
First Name:ELOISE
Middle Name:MARIA
Last Name:GONZALES
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06042-2086
Mailing Address - Country:US
Mailing Address - Phone:860-528-1359
Mailing Address - Fax:860-291-8990
Practice Address - Street 1:150 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06042-2086
Practice Address - Country:US
Practice Address - Phone:860-528-1359
Practice Address - Fax:860-291-8990
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-14
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT12.010540363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner