Healthcare Provider Details

I. General information

NPI: 1629796347
Provider Name (Legal Business Name): NICOLE GONZALES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2022
Last Update Date: 08/18/2022
Certification Date: 08/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3301 E 12TH ST
OAKLAND CA
94601-3424
US

IV. Provider business mailing address

276 CRAFTSMAN CT
LATHROP CA
95330-8679
US

V. Phone/Fax

Practice location:
  • Phone: 510-269-9062
  • Fax:
Mailing address:
  • Phone: 510-378-2390
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: