Healthcare Provider Details

I. General information

NPI: 1093243933
Provider Name (Legal Business Name): MARICELA GONZALEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2017
Last Update Date: 05/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5850 S MAIN ST
LOS ANGELES CA
90003-1215
US

IV. Provider business mailing address

4104 W 165TH ST
LAWNDALE CA
90260-3023
US

V. Phone/Fax

Practice location:
  • Phone: 323-897-6000
  • Fax: 323-846-4410
Mailing address:
  • Phone: 310-894-1892
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License Number657376
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: