Healthcare Provider Details

I. General information

NPI: 1699322941
Provider Name (Legal Business Name): SELINA GONZALES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2019
Last Update Date: 02/19/2026
Certification Date: 02/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 PICO AVE
SAN MARCOS CA
92069-3709
US

IV. Provider business mailing address

255 PICO AVE
SAN MARCOS CA
92069-3709
US

V. Phone/Fax

Practice location:
  • Phone: 760-290-2430
  • Fax:
Mailing address:
  • Phone: 760-290-2430
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number95355272
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: