Healthcare Provider Details

I. General information

NPI: 1124724695
Provider Name (Legal Business Name): KAYLIN SHAE GONZALEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2023
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1411 E 31ST ST
OAKLAND CA
94602-1018
US

IV. Provider business mailing address

827 LEVERING AVE APT 402
LOS ANGELES CA
90024-2737
US

V. Phone/Fax

Practice location:
  • Phone: 951-514-0049
  • Fax:
Mailing address:
  • Phone: 951-514-0049
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number199756
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: