Provider Demographics
NPI:1538397898
Name:GONZALEZ, NICOLE (IDMT)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:IDMT
Other - Prefix:MRS
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:HATCHER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:11758 SUMMER SPRINGS DR
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33579-4074
Mailing Address - Country:US
Mailing Address - Phone:813-919-3085
Mailing Address - Fax:
Practice Address - Street 1:8415 BAYSHORE BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33621-1607
Practice Address - Country:US
Practice Address - Phone:813-827-9330
Practice Address - Fax:813-828-7415
Is Sole Proprietor?:No
Enumeration Date:2009-06-25
Last Update Date:2009-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians