Healthcare Provider Details

I. General information

NPI: 1548139900
Provider Name (Legal Business Name): MIRIAM GONZALEZ RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2025
Last Update Date: 11/03/2025
Certification Date: 11/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 S VERMONT AVE
LOS ANGELES CA
90020-1912
US

IV. Provider business mailing address

PO BOX 3771
SAN DIMAS CA
91773-7771
US

V. Phone/Fax

Practice location:
  • Phone: 562-403-0101
  • Fax:
Mailing address:
  • Phone: 626-590-9367
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number95144011
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: