Provider Demographics
NPI:1871904458
Name:GONZALEZ, LAURA
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:LAURA
Other - Middle Name:KAY
Other - Last Name:GONZALEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3535 DENVER AVE
Mailing Address - Street 2:
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44055-2306
Mailing Address - Country:US
Mailing Address - Phone:440-233-2165
Mailing Address - Fax:
Practice Address - Street 1:3535 DENVER AVE
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44055-2306
Practice Address - Country:US
Practice Address - Phone:440-233-2165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-16
Last Update Date:2014-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3157006172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker