Healthcare Provider Details

I. General information

NPI: 1770838344
Provider Name (Legal Business Name): GRACE PERPETUA GONZALEZ LVN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2012
Last Update Date: 07/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15440 SHERMAN WAY APT 118
VAN NUYS CA
91406-4242
US

IV. Provider business mailing address

15440 SHERMAN WAY APT 118
VAN NUYS CA
91406-4242
US

V. Phone/Fax

Practice location:
  • Phone: 818-571-7961
  • Fax:
Mailing address:
  • Phone: 818-571-7961
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number72459
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License NumberVN265441
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number00471116
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: