Provider Demographics
NPI:1952111221
Name:GONZALEZ, KELSI LYNN
Entity type:Individual
Prefix:
First Name:KELSI
Middle Name:LYNN
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELSI
Other - Middle Name:
Other - Last Name:BROCKWAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3101 LATHROP ST
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-7426
Mailing Address - Country:US
Mailing Address - Phone:907-474-0890
Mailing Address - Fax:
Practice Address - Street 1:3101 LATHROP ST
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-7426
Practice Address - Country:US
Practice Address - Phone:907-474-0890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-09
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker