Healthcare Provider Details

I. General information

NPI: 1225933310
Provider Name (Legal Business Name): CHRYSTELLE INGRID GONZALES MARTINEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2026
Last Update Date: 10/09/2026
Certification Date: 10/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 W ROUTE 66
GLENDORA CA
91740-6207
US

IV. Provider business mailing address

530 E CYPRESS ST APT 10
COVINA CA
91723-1361
US

V. Phone/Fax

Practice location:
  • Phone: 626-852-5000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number95423171
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: