Healthcare Provider Details

I. General information

NPI: 1275801425
Provider Name (Legal Business Name): LISA ELIZABETH GONZALES CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2011
Last Update Date: 01/12/2026
Certification Date: 01/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 SUTTER PL STE 203
DAVIS CA
95616-6217
US

IV. Provider business mailing address

PO BOX 255228
SACRAMENTO CA
95865-5228
US

V. Phone/Fax

Practice location:
  • Phone: 530-750-5880
  • Fax: 530-750-5881
Mailing address:
  • Phone: 800-470-0071
  • Fax: 916-854-6769

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number0024169804
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberNM236574
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code176B00000X
TaxonomyMidwife
License Number0024169804
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: