Healthcare Provider Details

I. General information

NPI: 1396345948
Provider Name (Legal Business Name): MYLENE LILIAN GONZALES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2020
Last Update Date: 12/24/2025
Certification Date: 12/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 OGEECHEE DR
JOHNS CREEK GA
30022-1095
US

IV. Provider business mailing address

4700 OGEECHEE DR
JOHNS CREEK GA
30022-1095
US

V. Phone/Fax

Practice location:
  • Phone: 770-403-2186
  • Fax:
Mailing address:
  • Phone: 770-403-2186
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberRN249672
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberRN249672
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: