Healthcare Provider Details

I. General information

NPI: 1619672136
Provider Name (Legal Business Name): BROOKLYNN FAY GONZALES RN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2023
Last Update Date: 04/03/2023
Certification Date: 04/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1472 MORNING GLORY LN
ROSEVILLE CA
95747-7532
US

IV. Provider business mailing address

1472 MORNING GLORY LN
ROSEVILLE CA
95747-7532
US

V. Phone/Fax

Practice location:
  • Phone: 916-805-7227
  • Fax:
Mailing address:
  • Phone: 916-805-7227
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number95085152
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: