Healthcare Provider Details

I. General information

NPI: 1598482176
Provider Name (Legal Business Name): JULIETTE ANDREA GONZALEZ RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2022
Last Update Date: 03/04/2024
Certification Date: 03/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19722 MACARTHUR BLVD
IRVINE CA
92612-2404
US

IV. Provider business mailing address

200 S MANCHESTER AVE STE 300
ORANGE CA
92868-3219
US

V. Phone/Fax

Practice location:
  • Phone: 949-824-8770
  • Fax: 949-824-2698
Mailing address:
  • Phone: 714-456-2986
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86054085
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: