Healthcare Provider Details

I. General information

NPI: 1669301628
Provider Name (Legal Business Name): BETINA CARLA GONZALES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2026
Last Update Date: 05/15/2026
Certification Date: 05/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5178 HACKBERRY PL
BANNING CA
92220-1359
US

IV. Provider business mailing address

5178 HACKBERRY PL
BANNING CA
92220-1359
US

V. Phone/Fax

Practice location:
  • Phone: 909-825-7084
  • Fax: 909-894-7982
Mailing address:
  • Phone: 909-825-7084
  • Fax: 909-894-7982

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95324499
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: