Healthcare Provider Details

I. General information

NPI: 1548756695
Provider Name (Legal Business Name): ANGELA LYNN GONZALEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2018
Last Update Date: 07/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 E WALNUT AVE
LOMPOC CA
93436-7027
US

IV. Provider business mailing address

425 S I ST
LOMPOC CA
93436-7701
US

V. Phone/Fax

Practice location:
  • Phone: 805-735-3714
  • Fax:
Mailing address:
  • Phone: 805-315-5168
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number4715
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number069202417
License Number StateCA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: