Healthcare Provider Details

I. General information

NPI: 1417782467
Provider Name (Legal Business Name): NATALYA GONZALES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2024
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date: 12/30/2025
Reactivation Date: 08/18/2026

III. Provider practice location address

859 S YELLOWSTONE HWY STE 202
REXBURG ID
83440-5294
US

IV. Provider business mailing address

425 W 5TH S APT 55
REXBURG ID
83440-3420
US

V. Phone/Fax

Practice location:
  • Phone: 307-257-5487
  • Fax:
Mailing address:
  • Phone: 307-257-5487
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: