Provider Demographics
NPI:1669117222
Name:GONZALES, DOMONIQUE DESHAE (CNA)
Entity type:Individual
Prefix:
First Name:DOMONIQUE
Middle Name:DESHAE
Last Name:GONZALES
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4856 INNOVATION DR
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-5539
Mailing Address - Country:US
Mailing Address - Phone:970-494-4200
Mailing Address - Fax:844-270-1824
Practice Address - Street 1:4856 INNOVATION DR
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-5539
Practice Address - Country:US
Practice Address - Phone:970-494-4200
Practice Address - Fax:844-270-1824
Is Sole Proprietor?:No
Enumeration Date:2022-04-28
Last Update Date:2025-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CONA.00802613376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376K00000XNursing Service Related ProvidersNurse's AideGroup - Single Specialty